Coalitions in Healthcare: The Super Power of Pathways

"…then a nurse was telling me how they encountered a problem and how they fixed it…and I said 'No! Don’t do that way!'"* 

These are the words of Paul Levy, former CEO of Beth Israel Deaconess Medical Centre in Boston. His leadership style during the restructuring of BIDMC is studied in organizational behavior courses in postgraduate schools to illustrate decision-making and change management skills. But why would he be against local, grass-root level implementation of changes?

Change in healthcare is difficult, and it’s a fact. However, hands-on workers who see opportunity exist on almost every unit. And frontline staff are experts at what they do: they see problems first-hand, every day, they see unwanted effects and easily identify solutions to implement. They live in the here and now, and focus on what is. But as one of the core principles of the Gestalt theory of change asserts:

 "People are so wrapped up in seeing their reality through visions of how it was or how they want it to be […] that they don’t see the individual shapes or how those shapes all dance and tessellate together. They certainly don’t see how those patterns look as a whole picture."

Over time, staff give up voicing the same requests to overworked managers. They make it a priority to stay out of management’s line of sight. It is out of a human desire for creativity, or just out of plain frustration that they start working around the existing processes. But applying solutions can backfire; cutting corners might work for a while but can lead to tragic results.

The danger of workarounds is exemplified in Levy’s article in HBR, where he coins the term "The Nut Island Effect". It talks about an incident that happened on Nut Island, Massachusetts, where a handful of highly motivated workers formed a tightly knit group - a coalition. They took initiative and started to find solutions to fix problems, implementing entire processes to improve their workplace.

The workers were proud of their solutions and became infatuated, like a collective Narcissus looking into the waters (of Quincy Bay). An impoverished and distracted management contributed to a final, disastrous effect. Levy is using this case as an example of how in spite of good intentions, local, isolated initiatives can completely undermine entire strategies and the organization’s mission. He found the Nut Island effect rampant in hospitals and defines it as "a destructive organizational dynamic".

Just like on Nut Island, in healthcare we live and work on little islands, also known as silos. Each unit, whether clinical or administrative, has its own culture, politics and rules; however, they are functional groups, promoting internal collaboration. 

Lately, silos have earned a bad reputation and "breaking down silos" has been used as a slogan for sinking these islands of isolation. But the existence of the silos is not the issue. The real problem is the pathways that connect them. The trick is to connect these silos together effectively, in an operational network. Sadly, traditional organizations actively discourage connectivity, when, in fact, there is a blatant need for an informal structure, communication and a shared purpose. The evolution from hierarchical to networked organizations is seismical in nature: it shifts isolated islands together. 

  

Forming coalitions at lower and intermediate levels are an important source of power in healthcare environments. As a leader, you WANT and NEED these coalitions. You depend on the frontline workers as a source of expertise in their work and as a source of information. It’s a transaction. There is a crucial need to build links between these islands and be aware of the magnitude of this invisible pattern. As Levy says: 

"A common and long-standing feature of many public agencies and private companies, the Nut Island effect is often seen not as a pathology but as part of the normal state of affairs […]. It should serve as a warning to managers who spend the bulk of their time on an organization’s most visible and obvious shortcomings: sometimes the most debilitating problems are the ones we can’t see."

And once the whole is seen, it’s possible to move towards change.

@SimonaQHI

*Source: Interview in  "Paul Levy: Taking Charge of the Beth Israel Deaconess Medical Center" (Multimedia Case)
David A. Garvin; Michael A. Roberto, added on Sep 14, 2015 , on Harvard School of Business