Communicating In Hospital Environments Represents Unique Challenges

Introduction

Hospitals large and small are among the most complex “organizations” to understand with respect to human interactions and the processes/systems meant to manage those.  They are equally fascinating and frustrating to interpret and advise/counsel, respectively.  

The following article draws on the authors’ experience as management/operations consultants in hospital settings.  It discusses the communications characteristics unique to hospitals and some suggested remedies, particularly within the context of using communication as a change agent.

The Problem

Experience has shown that hospitals have difficulty meeting quality standards and financial targets when there is a lack of effective communication across the organization.  (This is certainly not exclusive to hospitals.  Every organization relies on effective communication to meet quality/financial objectives.)  More importantly, continued cost pressures coupled with new governmental reimbursement criteria has called on hospitals to change – to change the way they admit, treat and discharge patients, – to change the way they provide patient information, to name just two major areas.  Obviously, this would call on hospital staff to work a little differently.  Continuing the thought, this would call on hospital staff to align work (e.g., new reporting requirements) with the newly prescribed environment, learn how to exchange information, prioritize, reach consensus and change actions and behaviors in key situations – fairly quickly.  Informal/preliminary research conducted by the authors, however, indicates that hospitals have great difficulty communicating on an organizational-wide basis, and then rely on any such communication to result in meaningful, sustained change.  This conclusion is based on the following types of observations made in recent years:

• hospitals are more confederations than they are unified organizations – growth, hiring, promotions – mostly happen within proud departments (i.e., functional silos), each an organization in its own right competing for resources and perhaps going as far as denigrating the infrastructure; it’s not uncommon for nursing to bypass HR and do their own hiring or bypass procurement to order their own supplies; this is all well and good to the extent that sum of strong departments is a great hospital, but the stronger the internal organization (i.e., department), the greater the barriers for any kind of cross-departmental/organizational-wide communication; therefore, any communication not considered “local” (generated by the department the employee is working in) is usually delegitimized; the problem is, this fails to account for/accept anything necessary on an organization-wide basis and department communications tends to be extremely sporadic, thin or non-existent
• the schism between hospital staff and “administration, which helps ensure rejection of new ideas and general mistrust, has been institutionalized; the intensity of such institutionalization varies by hospital; such variations depend on a number of items, including press coverage, excessive compensation for senior executives, rancorous union negotiations, etc.
• cost pressures and workforce reductions have taken their toll on hospital staff; worn out people are less likely to join cross-departmental teams designed to seek out operational improvements or take the initiative to help out in the attainment of any other organization-wide continuous improvement goals for that matter – they ask, ‘What’s in it for me?’
• hospital communications/public affairs departments are not necessarily pro-change either; in many ways, they will publish content to help sustain the cultural status quo, one in which they have more trust in than one in which they don’t understand and are therefore skeptical about
• the composition of the workforce is a mixed bag; you’ve got full-time employees on hospital payroll, full-time doctors on a combination of hospital payroll and someone else’s payroll, volunteers versus paid employees, part-time and per-diem staff, highly educated and lowly educated, multiple shifts; it can be difficult to get everyone in the same book let alone on the same page
• for those staff that deal with emergency treatment, there is a tendency to “be on” in medical emergencies, and under such circumstances, communicate effectively, but in non-emergency situations, there is a tendency to “turn off” and mentally prepare for the next emergency; consciously or subconsciously there seems to be a decision made to communicate only when it is necessary; clearly, there is a medical necessity to communicate effectively across and within functional silos when a critical patient is being attended to, where the participants clearly understand the importance of crystal clear communication and teamwork under severe time constraints.  But isn’t it entirely possible that such intense situations would become the threshold for proactive communication?  That ‘if it isn’t a life and death situation, how important is it that we function as a winning team underpinned by constructive communication?’  

The Solution

While internal communication problems have plagued hospitals for years, current trends and events make the problem even more imperative to solve.  Every situation calls for a unique mix of interventions and implementations, but the following table explains that effective innovation is built on trust.  Here are a few ideas for meaningful action to address the obstacles cited above.

Problem	Solution
Departments Rule	At the start of any major change initiative, sit down with the heads of the key departments (i.e., finance, surgery, medical, nursing, IT, ER, pharmacy) and figure out what their needs are; do your best to meet their needs as part of an organizational change effort (e.g., integrating key provisions of the Health Care Reform Act); any conflicts need to be resolved at this point; as much as it sounds cliché, their “buy-in” is, in fact, absolutely critical and having them build out the model as a team working together is absolutely critical; their new togetherness needs to be publicized to the hilt so good or bad they are stuck with each other going forward
The “Administration” Says…	Oftentimes, hospitals are led by doctors who like to work quietly behind the scenes at fund-raising, trade/lobbyist and government events; this is great, but doesn’t build the necessary bridge with hospital senior management and hospital staff to affect any kind of rapid change within the hospital organization; what it does actually, is allow conflicts to fester at the department-head level and help ensure that obstacles – both overt and passive-aggressive resistance (e.g., arriving for meetings late; not attending meetings; not doing follow-up meeting work) to change remain firmly in place; study after study has demonstrated the positive affects of committed, visible, senior management to major change efforts; these same studies have shown that invisible CEOs have not had much success getting their organizations to change; this doesn’t mean plastering the hospital newspaper with photos of the CEO; yes, that’s part of it, but more important is the CEO and his or her key people sitting in on work sessions and holding people accountable for getting things done that allow the organization to change
Weakened/Jaded Troops	Since it’s not likely that hospitals are going to find the money anytime soon to beef up their administrative and clinical staffs, what management can do is manage around the key issues; employees are going to have to understand the importance of the changes that need to be made and that they will be held accountable for not participating/encouraged to take part through incentives (e.g., additional time off; financial performance bonuses)
Status Quo Communication	Communications staff are feeling particularly vulnerable these days so it is easy to get them to see themselves as victims by excluding them from all strategic planning sessions, meetings with management consultants, meetings with members of the board and so on; on the other hand, if you would prefer to position them as partners who are actively working with you to get the word out around changes that need to be made and organizational fluidity measures (breaking down barriers between functional silos), then invite them to all major planning sessions and make sure their performance reviews include some measures around contributions to major change efforts
Mixed Bag Workforce	Some basic theories still prevail irrespective of the composition of the workforce – they are: -          progressive disclosure: move the audience from general information to very specific information over a 2-3 month period of time – lead off with a visual piece (e.g., poster) setting the concept and a slogan and then keep reusing this logo/slogan in all subsequent communication -          demonstrate senior management’s support with a kick off letter, a kick off meeting and sustained executive visibility throughout the initiative until all goals are met -          use multi-lingual communication material as necessary -          set up blog pages/shared folders for team members to exchange information and meeting updates – make any such project-specific communication free of the hospital’s communication department’s policing function (e.g., logo violations) – exchange information between project-specific blogs and sanctioned hospital publications/websites to legitimize/validate formal and informal deliverables -          use podcasting, blogcasting and other new media tools to demonstrate progressive thinking, which is consistent with the nature of the organizational change
Emergency Thinking	This whole area deserves further research, but our initial thinking leads us to believe that there is some primitive human behavior at work here under the “fight or flight” theory.  This state of alert causes us to perceive almost everything in our world as a possible threat to our survival.  In this case, we are once removed; the threat is assumed by the patient and the responsibility for defeating the threat is assumed by the clinician.  If you’ve observed physicians, nurses, radiologists, surgeons, lab specialists communicating rapid fire in an emergency situation, then you’ve seen effective communication – designed to quickly affect change (i.e., the patient’s condition) – in action.  So this proves that change-driven, cross-functional communication can happen in a hospital.  It happens every day; the trick is to create an environment that would enable prompt, clear communication across functions when there is no real or perceived threat.  The key is to create a non-threatening forum because no threat senior management could come up with could possibly compete with a patient literally five seconds from death.  And how would you do that?  For starters, reflect on the symbolic power of bringing the department heads together early in the game and getting them on the same page; under these circumstances, department heads would be unlikely to condone counterproductive gossiping and bickering, and they would be likely to volunteer subordinate staff for cross-functional teams to take on new initiatives like integrating the new provisions of the Health Care Reform Act.   Further, reflect on the impact of a highly visible CEO or senior management team member sitting in on strategic planning sessions and work meetings, and reflect on how politically-charged hospital environments are.  Wouldn’t someone even marginally politically astute see themselves being put in a threatening situation by not being part of the new movement, under the visible leadership of the CEO and his or her senior management team?  Finally, a situation isn’t threatening if people are prepared for it.  That means they’ve been spoon-fed both local and hospital-wide information about the change from the get-go, written by in-house communications staff co-opted by senior management.  It also means they’ve been given the necessary training (e.g., Microsoft Project, Powerpoint, and Visio) to make a tangible contribution to the team effort at hand.

George Manderlink, PhD., and David Fitzsimons are Principals in the New York City-based Management/Operations Consulting Firm, thePiecesFit.