Wednesday, March 9, 2011

Leaders: Clear the path and your team will do their best work

Something a healthcare senior leader said recently gave me pause for thought.

As part of a group discussion around healthcare improvement, the perennial topic of electronic medical records (EMR) came up. While everyone at the meeting agreed that EMR would be hugely beneficial to patient care, X opined that technology couldn’t change attitudes.

Here’s the context: The group had already agreed that the primary driver behind healthcare improvement should be the philosophy of patient and family-centred care (PFCC). X’s point was that having EMR would be great, but it wouldn’t convert anyone from being provider-centred to patient-centred.

I spent the next few minutes of the meeting on a thought tangent.

X’s assumption was that providers are fixed in a self-centred existence. They have to be “re-educated” and convinced to embrace PFCC. EMR and other technology don’t influence behaviour.

But, what if there’s a different explanation? Let’s assume that every nurse, doctor, clerk and housekeeper would get tremendous satisfaction from applying PFCC principles in their daily work. They may not be familiar with the formalities of PFCC, but they understand what it means to be kind and caring. Further, assume that all newly-hired providers come to their first day of work with the desire to do their best to serve their patients. What happens after that?

We beat the PFCC out of them! We put obstacles in their path, fail to reward (or even punish) sincere efforts to put patients first. We make it easier to be self-centred than patient-centred.

Here’s an EMR-related example from my practice: A man is referred to me with pain in his side, possibly related to a kidney stone. I recommend a CT scan to locate the kidney stone. He tells me that he already had a CT scan done at his local hospital. The referral letter didn’t indicate that a CT had been done, so I didn’t have the opportunity to look at it prior to this visit. I try to access the CT films using the online x-ray viewing system, but as is frequently the case when we try to do this from our office, the system is not working. I tell the man that I will check his CT the next day when I’m at the hospital and can use that system. He leaves without a definite diagnosis or treatment plan.

Another common example is the “missing” lab test. When a patient has already had a certain blood test performed, but the attending physician doesn’t have access to it (e.g. it’s a weekend and the family doctor’s office is closed), it’s just “easier” to poke the patient with another needle and repeat the test. The physician ordering the repeat test isn’t deliberately cruel; if the results were easily available (EMR!), it wouldn’t be necessary to stick the patient again, and it wouldn’t be done.

My conclusion was that X should think about healthcare providers’ behaviour differently. Rather than presuming the worst, X should assume that providers naturally want to provide PFCC, and that “the system” impedes them. If we assume the best, then our approach would change from one of trying to educate providers in PFCC, to one of trying to remove the barriers that prevent them from fulfilling their natural inclinations.

Here’s what this means for a leader: If your staff isn’t delivering PFCC, it’s not because they don’t want to. It’s because you have not created an environment that lets them do their best work.

Clear the path. Unleash the potential.


  1. I agree that effective leaders need to "clear the path" of obstacles that impede the team from being patient & family centered. Not sure though that "understanding what it means to be kind and caring" automaticly transltes into PFCC. A lot of komd and care workers strive to do the right things FOR patients but don't garsp what it really means to work WITH patients to meet their needs.

  2. Thanks, Anonymous (this blog's #1 commentator!). Right you are! There is a big difference between doing for (patient-focused) and doing with (patient-centred). That difference will be challenging for some people to garsp. How can we help them?

    Will education be necessary? Of course. I was being provocative in the post - I don't really believe that we won't all need some orientation to PFCC. It's a new skill for most of us, and we can't expect to pick it up without training and practice. But I think all the training in the world will be wasted if workplace barriers persist.

    A combination of staff education and workplace design will be most effective.

  3. I was struck by your blog as just last week the lack of an EMR and EHR once again was an issue for us. My daughter has a blood disorder and juvenile arthritis. We recently spent 6 out of 7 days in the ER for treatment from an virus that posed risk to her blood disorder. Each day we went back to receive an intervenous antibiotic. During one of our trips, we also had an appointment upstairs with one of her specialists. The specialist was aware my daughter was in the ER, because they had alerted her after I told them we had an appointment. When we arrived at our appointment, the results from my daughter's bloodwork from 36 hours prior had not yet arrived. Luckily I now know this will be the case and I ask for copies so I was able to provide my copy to be photocopied for her file. (I also keep a list of the providers that must be alerted to the results of any tests my daughter receives in her "medical binder" that we carry with us.)

    Bloodwork had also been taken that morning and after our appt upstairs we made our way back down to the ER to receive the results before we went home.

    I am grateful for the dedication that all the doctors, nurses and admin provide us. I cannot say enough about the great care we receive at every visit and between visits. But I agree they are limited by the system they work in. So I don't fully agree with X. I think EMRs and an EHR will help to move the system to a more patient-centered care focus.

    If there was a system that allowed all the providers on my daughters care team to communicate in real time I could be a mom. A mom that hugs her daughter when they have to take blood, reads her stories to alieve her fears and spends her evenings planning for her daughter's next dance recital rather than reorganizing and updating her "medical binder" so the next time we visit someone from her care team I can provide an update. As a mom I think that would be a pretty good step toward PFCC.

  4. Thanks for the comment. Please see "A mother's voice speaks loudly and clearly for EMR and PFCC" (March 13, 2011) for a reply.