Leading a Hospital Unit Effectively

Leading and creating a hospital unit workplace culture, where people want to be. A provocation for generative thinking.

Shanafelt et. al. have demonstrated and concluded that creating a wellbeing culture in healthcare needs to happen at the local unit level.1 Professors Amy Edmondson and Don Berwick delivered a keynote together last week at the IHI BMJ International Forum on Quality and Safety in Healthcare, in London, where they encouraged healthcare organisations to start testing new ways of managing and delivering healthcare in “intelligent ways”.2

Importantly Amy recognised clearly that context always matters. I think Tait Shanafelt and colleagues would absolutely agree, which is why local unit level is their recommended place for culture development in hospitals. Amy suggests in her book The Right Kind of Wrong3 that the two important questions to ask to establish context are:

  1. What’s at stake?
  2. How much uncertainty is there?

With these in mind she encourages intelligent risk taking and being explicit that this is an experiment. “The only way forward is if we are learning together, effectively in real time” she said near the end of her conversation with Don.

Prof Berwick added such wisdom, noticing that within a group there’s always “an observing consciousness, with the intention to learn present, distribute the consciousness so there are literally structures supporting that everywhere” he advised. “Increase the odds for people to see and learn” he said.

Together they concluded we need to allow people to “get started” with the support of those in power holding an attitude of “I’ve got you”.

While this is all incredibly inspiring, it remains unclear what to do to be an effective leader of your actual hospital department.

If you are a department or unit leader in a public hospital, wondering how to support your clinicians you have probably tried lots of things, genuinely, with good intent. I’m guessing from the many conversations I have had with your colleagues that it feels pretty hopeless at times, and that just keeping your head above water feels like an achievement. That’s because it is. Your body is telling it like it is.

So how can we really run these experiments in our hospital units? 

Healthcare is the hardest environment for leaders. The father of modern business management, Prof. Peter Drucker described healthcare as ‘managing a two-headed monster’4. Unit leaders are sandwiched between administrative leadership and clinicians, with inadequate resources, exhausted staff and the critical need to keep patients safe. However, this does not mean that the psychological safety of the healthcare workers can be ignored or harmed, and creates a lot of pressure for hospital unit leaders.

Patient safety is top of everyone’s minds, all the time, and yet it is undermined in so many ways, some that are outside even the unit leader’s control. 

Appreciative Inquiry offers us a process to envision a way forward, beginning with Define, Discover and Dream. With a great deal of liberty to dream, grounded in the advice of Edmondson, Berwick and Shanafelt I have painted a picture that I am about to share with you. 

Appreciative Inquiry5 begins with Define. The question I asked myself was; 

What would a Head of Department in a large tertiary hospital department in Australia need if they were truly going to create the workplace they wish for, and describe to me, during coaching?

See if you can resist the default urge to critique the vision. Instead dream a little yourself, shake off the usual limitations. Often, we can’t get unstuck because we don’t have any idea where we are trying to go. The kind of visioning that follows below is not a recipe, it’s an exploration to see what arises, as you imagine. It’s one way to create some new thinking, it’s optimistic and descriptive, rather than prescriptive.

We need some parameters

To reset a large hospital department and create a culture that fosters growth and better provision of healthcare, I would start with a testing timeframe of 24 months. Evaluation would be ongoing throughout, reported at least at 3-6-12-18-24-28 months. 

First Steps – Discover

Meet with the executive team in whatever composition you can, to start the conversation. Tell them about the research, let them know you are thinking deeply about the wider frame. Share with them the demonstration model of Sir Charles Gardiner Hospital in Western Australia6 who have become the employer of choice for junior doctors in the whole country, through radical realignment, listening to clinicians, a willingness to experiment and utilising technology.

Begin a conversation that invites the executives to collaborate and support. Seek to understand what they want to see from your department, what the specific pressures are for them in relation to your department. 

Share your vision for your department, for the patients, the people who work there and for the organisation. Speak to how the vision could help to relieve any of the current problems, for example, retention and attraction of quality skilled staff. You could share some of the resources included below. 

Explain that you are seeking to establish a process that is resourced, so that you can collectively learn, that you don’t know what all the outcomes will be, until you create the environment for distributed consciousness, intelligent failures, and learning

Invite them to champion and fund the work for a defined period of time (at least two years).

Action Plan – Dream

1 deputy who is paid appropriately for their added responsibilities and has the appropriate time allocation, at an appropriate ratio for the work your department does, perhaps 1:30 team members (eg in a Unit of 100 people there would be 3 Deputy Heads of Unit who probably work in this role at least 2/7).

1 executive assistant working with the team of leaders, full time

(eg. the Head of Unit and 3 Deputies, perhaps the NUM)

1-2 planning days as a leadership team every 6 months, or the equivalent hours in team coaching, to really focus on what you are seeking to create and to learn together, locally.

12 – 24 months of individual coaching for the leadership team and other senior staff responsible for teaching and setting the tone within the department.  

Regular huddles and feedback processes with all staff, shared across the leadership team and standardised, with regular test and reset modes built in. The EA is the likely coordinator of these processes. The coaching team may be involved in shadowing or observing the process as part of the leadership development, especially in the first 12 months. 
Regular, standardized feedback loops established with the patients of the unit. The EA will coordinate this process too and the executive team will be looking at the data every month in their administrative meetings. Trends can be considered in coaching and at the planning days.

Regular engagement with representatives of the hospital Executive team and Board, perhaps every 3 months. 

Utilise technology in the areas the team identify as important. Collaborate with those who have the requisite skills on the specific needs identified throughout the process described above, IT personel for example.

Mixed group of health professions in discussion around a boardroom table. A projected chart of data is being displayed on a screen behind the medical professionsal

There will be other specifics for the local environment, there is lots of room to flex. This article hopes to provoke clear planning and action, and hope, so that we can move forward. Imagine what could be achieved if this was your implementation strategy!

The administrative support is key to this vision, releasing doctors to do the work they are essential to, and optimising funding resources. Medical leadership is an expensive resource to be running logistics and this is not the primary skill set of most unit leaders. They need to be released to focus on the effective delivery of medicine and leading the team. 

Funding is always an issue. To create something that is next level is exciting and often stymied by an inability to dream and/or to let go of the old. Be curious, see what could be possible…it’s amazing what money can be found for, once people are actually clear and articulate about what they need and where they are going. 

To demonstrate how to lift healthcare teams to the next level, we will need radical investment in the short term. That’s the nature of true investment. It’s different to the kind of fire fighting, survival mentality currently practiced in so many hospital units. Continuing to expect effective leadership in hospital units by tweaking the edges has gone on long enough. 

Over to you. 

What can you envisage? 

Who can help you create some of your better hospital department culture? 

Where can you start?

  1. https://www.researchgate.net/publication/355015491_Physician_Well-being_20_Where_Are_We_and_Where_Are_We_Going. ↩︎
  2. https://internationalforum.bmj.com/london/live-from-london-2024/ ↩︎
  3. https://www.booktopia.com.au/right-kind-of-wrong-amy-edmondson/ ↩︎
  4. https://www.researchgate.net/publication/281190268_Complexity_in_healthcare_management_Why_does_Drucker_describe_healthcare_organizations_as_a_double-headed_monster ↩︎
  5. https://organizingengagement.org/models/appreciative-inquiry/#:~:text=The%20Principles%20of%20Appreciative%20Inquiry&text=In%20a%20later%20formulation%2C%20Cooperrider,Poetic%2C%20Anticipatory%2C%20and%20Positive. ↩︎
  6. https://www.scgh.health.wa.gov.au/News/2022/12/14/Junior-Medical-Officer-Manifesto ↩︎