5.1 A Brief Introduction

In the last chapter, I highlighted some strategies that healthcare leaders can use to help them promulgate company-wide cultures that support continuous improvement (CI) initiatives. However, in my opinion, a healthcare firm will rarely be able to succeed in integrating CI into its corporate routines unless the institution has the support of its frontline supervisors and their staffs. The corporation’s executives can come up with excellent ideas for getting employees to buy into Six Sigma, Lean, and other CI methods. However, their plans will go astray if the organization’s administrators fail to foster the right type of office environments.

I begin this chapter by showing readers why a healthcare institution must ensure that each of its departments possesses a CI-supportive culture if it wants to incorporate Lean, Six Sigma, or other continuous quality improvement (CQI) methodologies into its corporate infrastructure. I look at some of the problems that a hospital or other health services firm might encounter if even one or two of its units are hostile to CI initiatives. Throughout this narrative, I define departmental cultures that are inimical to CI as dysfunctional because I believe these workplaces often possess traits that hinder organizational processes, which are unrelated to CI. By contrast, I refer to office environments that support CI projects as high-performing cultures. That is because I feel a workplace that sustains CI-related methods will also oftentimes be one that is best suited for achieving other types of corporate goals.

I note that, while high-performing office environments are supportive of CI, they do contain and even embrace some types of inefficiencies. I explain to readers why this is the case. Next, I identify key traits that many or most of the employees in a CI-supportive department should possess. I then touch on some additional skills that an office’s staff might require in order to make optimal use of CI methods. I go over each of these characteristics in more detail and show why workers need to have them. Just as important, I suggest strategies that administrators can employ to ensure that their particular department culture fosters these traits. I will utilize information from the previous chapters to help me to frame this discussion.

5.2 Where CI Is Concerned: Dysfunctional Departmental Cultures Can Waylay the Best-Laid Organizational Strategies

Dysfunctional departments, defined here as ones whose staffare not supportive of CI, can wreak havoc on an organization’s quality improvement (QI) initiatives. Speaking from experience, I can attest to the power of recalcitrant workers to stymie company-sponsored initiatives that they do not agree with. Employees can achieve these aims either by declining to go along with certain key workflow-related changes or by refusing to complete CI tasks in a timely manner. Staff who work in dysfunctional units might also cause difficulties for CI-focused administrators if these subordinates are not engaged in the process. In these instances, the individuals may not put forth the required effort to make sure that their respective firm’s CI strategies succeed. At the same time, people who are not in tune with the company’s CQI efforts—or who are dissatisfied or disgruntled—might not work well with their peers when placed on QI teams. Their antisocial behaviors will likely impede the group’s ability to identify the root causes of problems and implement desired improvements. Many researchers would agree with my arguments. For instance, Bruce Fried and William Carpenter, two well-known healthcare experts, note that it is very difficult for improvement teams to thrive when their members are part of cultures that exhibit “intense and dysfunctional competition, low staff participation in decision making, and interprofessional rivalries” (Fried & Carpenter, 2013, p. 137).

These are just a few of the problems that a healthcare organization may run into in implementing a corporate-wide CI process when some of its departments possess dysfunctional employee cultures. I am sure that readers can point to many more such issues that might result from these types of situations. And sadly, at least in my experience, it only takes a few CQI antagonistic units—or a small portion of the employee population—to disrupt corporate-wide CI initiatives.

By the same token, administrators in dysfunctional departmental cultures will probably have difficulty in implementing office-level CI initiatives. In my experience, these supervisors will have trouble getting their employees to buy into CI-related methodologies. Even if the managers or professionals with de facto power are able to make a QI-based change, they will run into problems in convincing their workers to put in the effort necessary to make these improvements stick. Granted, an office-level healthcare leader might be able to force staff, via threats or other autocratic means, to accept a certain QI process. However, his or her success will likely result in a pyrrhic victory that causes more problems over the long run (e.g., by negatively impacting employee morale) than it solves.

5.3 From the Point of View of CI: Key Aspects of a Dysfunctional Culture

I want to briefly delineate some of the key aspects of a dysfunctional culture, which I define as one that is not amenable to CI methods. I do not plan to discuss every possible issue. Rather, I hope to use these examples to help me demonstrate how a dysfunctional office environment can derail an organization’s CI-focused initiatives. Though I only focus on CI-related subjects here, it is worth noting that these types of employee cultures are often not conducive to the use of the best practices management techniques discussed in Chapter 2.

• Disengaged Employees: In my experience, dysfunctional cultures tend to possess a large number of unmotivated individuals. They often give less than 100 percent effort while on the job. These people might not care about the quality of their work. Some disengaged staff may also take shortcuts whenever they can get away with doing so. Stating it in another way, these employees “do not put their hearts and souls” into their jobs.

  It is safe to say that few if any office-level healthcare leaders want to manage unmotivated individuals. These employees can cause a host of problems for the administrator, in particular, and the company, in general. I will focus more attention on this topic at a later point in the book. With regard to CI, a healthcare supervisor will be hard-pressed to incorporate Lean, Six Sigma, or similar methods into daily work processes if a critical mass of workers is disengaged. To wit, almost every employee, whether he or she is directly involved with CI projects or not, will have to put in time and effort to make sure that CQI initiatives get off the ground. Unmotivated workers will often lack the necessary commitment to ensure the success of these CI ventures. One group of healthcare researchers summed up this issue quite well when they stated that, “[E]ven the most technically precise quality management program will fail if employees are unmotivated and lack commitment to the program’s success” (Lam, O’Donnell, & Robertson, 2015, p. 212).

• Disruptive Workers: Some dysfunctional office cultures might not just contain large numbers of disengaged workers; they may also harbor a critical mass of disruptive employees. Among other things, these people could be frustrated with certain corporate policies, unhappy with their jobs, or angry with their managers or peers. These individuals often express their dissatisfaction with the status quo by refusing to help their coworkers or by declining to take part in new corporate initiatives, including CI projects. They might even actively work to undermine CQI ventures (Wyles, 2016, pp. 30–31). Healthcare organizations that harbor large numbers of these workers will have obvious difficulties in successfully implementing CI-based initiatives.

  Most healthcare firms of any size will likely have at least a few disruptive employees. However, in my experience, organizations with dys-functional cultures often shelter a larger percentage of these types of staff members. And from what I have seen during my career, if these employees make up even a small percentage of the workforce, they can do a lot to hinder CI initiatives (or, for that matter, any type of project).

• Self-Interested Staff Members: In the last chapter, I noted that a health-care organization that wants to successfully incorporate CI strategies into the workplace should possess employees who, by and large, are team players. Along the same lines, an office-level healthcare leader has to make sure that his or her subordinates are “company-first” types. An administrator who manages a department full of self-interested individuals will find it more difficult to implement Lean, Six Sigma, or other CI processes. For one thing, he or she might have difficulty in getting these staff members to participate in interdepartmental QI teams (Fried & Carpenter, 2013, pp. 136–137). At the same time, the self-absorbed workers, adhering to an “all for me” mentality, might refuse to put in the extra effort that would be required to ensure the success of a CI program.

• A Dearth of Trust: It is common knowledge that when employees have faith in their supervisors, they are often more willing to behave responsibly, work hard, and do the other things necessary to help their departments succeed. In my experience, an office-level healthcare leader who has the confidence of his or her subordinates will have an easier time in convincing these people to buy into Lean, Six Sigma, or some similar method. At the same time, if staff trust this administrator, they will be more likely, all other things being equal, to work harder to make the CI transition process a success. Researchers and business experts have corroborated my observations; their studies indicate that the success or failure of CI initiatives is dependent, at least in part, on the level of trust that exists between employees and management (De Leede & Kees Looise, 1999, pp. 1198–199; Elliott, 2008, p. 58).

  In my experience, employees who work in dysfunctional workplaces often distrust either their immediate supervisors or higher-level managers. In some instances, these people might not put a whole lot of faith in any of their leaders. In the worst cases, staff members are suspicious of everyone in the department including their coworkers. Readers can see how difficult it might be for an administrator to implement and sustain CI projects if he or she works in this type of office environment.

• Misaligned Incentives: Even the most enthusiastic employees will have difficulty supporting CI initiatives if they do not have a reason to do so. In a dysfunctional culture, the healthcare organization or its specific departments will often fail to properly incentivize staff to adopt CI methods, or they will create inducements that serve to discourage workers from adhering to CI principles (Sollecito & Johnson, 2013b, p. 64; Upshaw, Steffen, & McLaughlin, 2013, p. 300). Even when a healthcare company makes a good-faith effort to align its incentives with CI-related goals, its exertions in this regard might still not be enough. To wit, the corporation must also identify and ameliorate any embedded elements within its departmental cultures that encourage employees to exhibit apathy or even hostility towards Lean, Six Sigma, or similar CQI strategies (Pinc, 2013). For example, staff members who work in an office environment that encourages them to “go with their gut instincts” when solving problems might be disinclined to support Six Sigma’s empirical methods.

• A Lack of Know-How: Most readers would consider it common knowledge that a healthcare firm needs to employ a critical mass of people who possess certain technical skills if the organization successfully wants to incorporate CI methods into the workplace. However, if a company is serious about adopting Lean, Six Sigma, or the like, it must also make sure that staff in each department have a range of non-technical abilities. At least some employees in these units must be able to do things like work in a team-oriented environment, possess the ability to critically analyze processes at the meta level, have the courage to question things, and understand how various work-related systems interact with each other.

  I will focus on some of these non-technical skills later in the chapter and delineate their importance to the success of CI-related projects. Here, I simply want to note that, in my experience anyway, dysfunctional workplaces often lack people who have the aforementioned traits. In some instances, this dearth might be due to management’s inability to hire individuals who possess the requisite abilities. However, I think that the problem is more often attributable to issues with an organization’s or department’s employee culture.

  Healthcare firms may sometimes be unable to integrate CI processes into their workplaces because of cultural impediments. For instance, the corporate environment might not incentivize employees to develop critical thinking or analytical skills. In other cases, management may discourage open communication by punishing workers who point out flaws in work routines or care processes (Blair, 2013, p. 60). At the same time, healthcare administrators who condone workplace bullying might deter individuals from pursuing key non-technical skills. I can attest from experience that this type of situation will stifle employee development. These are just a few of the many ways in which an office’s dysfunctional elements may impede its workforce’s ability to acquire and develop key non-technical skills.

5.4 A Case in Point: A Dysfunctional Claims Department

As I noted previously, a healthcare organization might have difficulty implementing corporate-wide CI initiatives if any of its departments possess dysfunctional cultures. I have created this short scenario to help illustrate the point. While both the story and the characters are fictional, I have drawn my material from situations that I have observed over my healthcare career.

Jerry is the supervisor of the commercial insurance claims department at a durable medical equipment (DME) company. He believes in utilizing authoritarian leadership practices. Jerry employs coercion and fear-based tactics to motivate his staff. The manager routinely and sometimes publicly berates individuals under his command when they make (what he perceives to be) mistakes. Jerry inconsistently enforces the department’s rules. Additionally, he seems to favor some employees over others. As problematic, the administrator does not always complete his employees’ yearly reviews on time or respond quickly to their queries.

The office culture is less than ideal. While one or two employees are relatively content, on the whole, worker morale is quite low. A number of people complain loudly and publicly about the office environment. Some of them are so disgruntled that they refuse to answer questions from their coworkers. If a staff member possesses knowledge that gives him or her an advantage over others, that person is reluctant to share this information. He or she is likely only going to disseminate this data to colleagues on a quid-pro-quo basis. A visitor who happened to step into the unit would describe the atmosphere as “tense.” Only a couple of the staffhave formed friendships or even strong acquaintanceships. Few of these individuals are motivated. Instead, most of them only put in a minimal amount of effort unless Jerry “cracks the whip.” The department’s annual turnover rate is over 50 percent, which is quite high. Most of the employees in the office are looking for other jobs.

The department’s staff are, on the whole, not that efficient or effective. Although these people can do much of their work on computers, they must know and utilize several different software programs. At the same time, the employees still have to do some things by hand. As a result of these issues, they waste time in performing redundant tasks and in switching back and forth between screens. Although Jerry utilizes an authoritarian style of management, he rarely walks by his workers’ cubicles. Instead, he rarely leaves his office unless he has to attend a company-related event or speak to a fellow supervisor. Taking advantage of this fact, most of the individuals in the department spend a signifi-cant amount of time on extracurricular activities, including surfing the web and conversing with friends on social media.

The organization’s CEO wants to reduce costs by streamlining the company’s revenue cycle management system and has asked all relevant departments to participate in this endeavor. In the supervisors’ meeting, the executives and administrators decide to create an interdisciplinary team to identify areas of improvement in the firm’s workflow processes. Additionally, each office-level leader agrees to explore ways to enhance operational efficiency and productivity in his or her unit.

Jerry goes back to his work area and tells his subordinates that they need to “do a better job around here.” He commands them to put their heads together and come up with some ways of improving the claims submission and appeal processes; however, he does not provide them with any additional guidance. The manager takes a quick look at the staffand chooses one of the more disgruntled workers to serve on the interdisciplinary committee. When the employee asks Jerry for more information about the team, the administrator says, “Contact Martha in sales; she is the project leader.” Jerry then heads back to his office.

Anyone who has worked in healthcare can likely guess how this story ends. Jerry’s staffmembers are probably not going to be able to successfully implement any type of CI-related initiatives. At the same time, the disgruntled staff member, who Jerry has assigned to the interdisciplinary team, is more likely to hinder than to help the group’s efforts. The employee can stymie the team’s ability to do its job by getting into needless arguments with peers, by refusing to help come up with ideas, or in any number of other ways. Although this story is fictional, it illustrates real aspects of dysfunctional cultures and shows how they can derail CI projects. Importantly, from what I have seen for myself and via my discussions with other people who work in the field, a number of healthcare organizations possess these types of dissonant office environments.

5.5 High-Performing Cultures Embrace Some Employee-Related Inefficiencies

Employees at even the best-run healthcare organizations will not perform at optimal levels all of the time. They are human beings, and as such, they are prone to getting distracted, working at subpar speeds, and performing tasks in an inefficient manner. Additionally, staff might sacrifice output levels in order to experiment with new techniques and practices. At the same time, in a participatory culture anyway, people will sometimes complete tasks more slowly than normal because they are busy answering a colleague’s questions or otherwise helping their peers out (McShane & Von Glinow, 2015, p. 27). An individual might also work at a slower than customary pace in order to spend more time conversing with a resident or patient. These are just some of the many reasons why healthcare workforces will never achieve optimal rates of efficiency or effectiveness.

All healthcare supervisors, including ones that oversee CI-supportive environments, have to deal with employee-related inefficiencies. However, in my opinion, office-level healthcare leaders who are part of high-performing cultures usually do a much better job than their peers of managing their workers’ “wasted” time. To wit, administrators in CI-focused departments take the opportunity to get to know their subordinates and thereby are cognizant of each staff member’s inefficient activities. Some supervisors might even be aware of the specific points during the day when their employees are least productive. Managers and professionals with de facto power who oversee high-performing workplaces approach the topic from a cost–benefit perspective (more on this subject in the proceeding paragraphs). The best office-level healthcare leaders usually know when to curtail a person’s non-productive activities. They also can often recognize when workforce-related inefficiencies are symptoms of larger issues.

As I noted in the previous paragraph, healthcare administrators who utilize best practices management techniques employ a cost–benefit approach when deciding what if anything to do about staff-related inefficiencies. Most readers are already familiar with the expenses that can accrue to an organization as a result of “wasted time” so I will not touch on that issue in this chapter. Instead, I will focus on ways in which a department or organization might benefit when it overlooks or even encourages some types of non-productive employee-related behaviors.

• Employees Are Less Likely to Leave: Even great employees spend a percentage of their workdays performing non-productive activities, including staring off into space, checking their phones, or surfing the Internet. In my opinion, a good administrator allows his or her staff to do these things as long as they, to borrow an old cliché, “get the job done.” From what I have seen, people who have some control over their work pace are generally happier than their counterparts who are part of more regimented systems. And as research has shown, happier workers are more likely than less-contented peers to stay with their current employers (Barbian, 2001, p. 93; Cooper, 2012). It goes without saying that managers and professionals with de facto power will have an easier time introducing and maintaining CI initiatives when their workforce is stable.
• Workers Are More Engaged: In my experience, the more autonomy that staff have, the greater the chance that they will engage in some inefficient practices. On the flip side, employees who have some freedom to control their office routines tend to be more engaged than their counterparts who work in highly structured, micromanaged environments (Barbian, 2001, p. 93; Blyth, 2007). In many cases, a healthcare administrator would be wise to allow his or her workers to exert some control over their day-to-day activities because the benefits related to increased employee engagement outweigh any costs from wasted time. Looking at it from a CI-focused standpoint, this is especially true given that both the healthcare organization and its individual departments need to possess a critical mass of motivated people if these entities are going to incorporate CQI methods into their infrastructures.
• Staff Are More Productive over the Long Run: In my experience, employees, on the whole, tend to be more productive over the long term when they have some control over their daily routines. For instance, a staff member, if left to his or her own devices, might work at only 80 percent of the optimal rate from 1:00 p.m.–2:00 p.m. However, the person uses this time to recharge and is thereby able to exert maximum effort from 2:00 p.m.–5:00 p.m. A healthcare administrator who wants to micro-manage his or her subordinates might be able to coerce a worker to pick up the pace during the 1:00 p.m.–2:00 p.m. block, only to find that the individual slacks off from 2:00 p.m.–5:00 p.m.
• Employees Put More Trust in Management: In my years working in healthcare and speaking with others in the industry, I have noticed a correlation between an employee’s level of trust in management and his or her degree of job-related autonomy. Namely, people who have more control over their work routines—or at least possess some ability to modulate the pace of their activities—tend to be more faithful to their administrators. Some readers might question this relationship; however, studies provide support for my observations (Krone, 1994, pp. 218–219).
• Workers Have More Self-Confidence: As I will discuss later in the chapter, healthcare organizations need to possess a critical mass of self-confident employees if these companies want to successfully incorporate CI methods into their workplaces. Staff who have some autonomy and are allowed to experiment with new ways of doing things are often more self-confident than their peers who work in stifling, micromanaged environ ments (Marmot, 2003, p. 574; Webb, n.d.). However, as everyone knows, when one has the freedom to improvise, he or she is going to make some mistakes. At the same time, this person will devote time to activities like brainstorming that, in the short term anyway, reduce his or her efficiency ratings. In CI-supportive cultures, management accepts these tradeoffs.
• Staff Are Able to Develop Their Critical Thinking Skills: In my experience, employees are able to improve their critical thinking skills when they have the freedom to tinker with their work routines—to plan out the changes and test to see if these adaptations are successful. Via this process, staffdevelop a knack for spotting systemic flaws and identifying potential solutions to these problems—skills that are important in a CI-focused workplace. Many healthcare and business experts agree with me on this point (Snyder & Snyder, 2008, p. 93; Wilson, 1998, p. 34). Of course, employees who perform these types of mini experiments will, at times, be less efficient than their peers who do not try out new techniques. When possible, healthcare administrators who are part of high-performing cultures allow their subordinates to experiment with new ways of doing things because these leaders realize that the long-term benefits outweigh any short-term costs (with regard to lost productivity).

In short, healthcare administrators must not attempt to micromanage every staff-related activity with an aim to maximizing productivity. Instead, they should assume that their workers will operate at less than 100 percent efficiency some of the time. A good manager or professional with de facto power will design workflow processes that account for these employee-related inefficiencies. At the same time, the office-level leader will work with subordinates to eliminate or at least ameliorate time-wasting activities that provide little or no net benefit to the department or organization.

5.6 Cultures that Support CI: Key Employee-Related Traits and Perspectives

In the first part of this chapter, I touched on cultural elements that might impede a healthcare organization’s ability to adopt and implement a CI system. As part of this discussion, I identified some employee-related behaviors that are not amenable to CI ideals. Now, I am going to change course and focus on staff-related traits that are supportive of CI initiatives. I believe that a healthcare company needs to ensure that its workforce possesses several key abilities and mind-sets if the institution wants to successfully incorporate CI methods into its operating protocols. These include:

• Self-Confidence
• Possessing a Degree of Autonomy
• Job Satisfaction
• A High Level of Motivation
• A Team Player
• A Sense of Loyalty to the Company and Stakeholders
• Bonds of Trust
• A Willingness to Accept Change

In the next part of this chapter, I will go over each one of these traits in more detail. I will demonstrate why a healthcare organization, at the very least, needs to contain a critical mass of employees who possess these abilities and perspectives. At the same time, I will posit ways in which office-level healthcare leaders can help their workers to develop these traits and mind-sets.

5.7 Employee Self-Confidence Is a Key Trait in a CI-Focused Workplace

I think almost everyone will agree that a department performs better when its staff members possess at least a modicum of self-assurance. In my experience, workers who are confident in their abilities tend to be more efficient and effective. These individuals are more productive in part because they do not waste time needlessly worrying about whether they can perform required tasks. Although they ask coworkers for help when necessary, they do not slow themselves and others down with frivolous or superficial queries. At the same time, they do not let small issues hinder their progress. Instead, self-confident people find ways to overcome these dilemmas. Granted, employees can become too haughty to the point at which they refuse to follow company guidelines or to accept criticism from supervisors or coworkers. However, in my experience, few if any staffmembers reach this point. Quite the opposite, too many workers lack the requisite self-assurance to perform at optimal levels.

Focusing specifically on CI, healthcare organizations that want to incorporate CQI principles into their infrastructures should seek to create office cultures that foster employee self-confidence. In my experience, self-assured staff members are more likely to inform their supervisors about workflow-related issues or other service-related problems. These individuals are also more apt to accept changes in their work routines because they have faith in their ability to adapt to these alterations (Seidenfeld, 2013). Perhaps most importantly, self-confident employees are more likely to take ownership of their work (Fox, Byrne, & Rouault, 1999, pp. 38–40). From what I have seen, these types of people will usually strive to ensure the success of any CI projects that they participate in.

Given the relationship between employee self-confidence and the success of CI initiatives, office-level healthcare leaders should seek to promote departmental cultures that foster this trait. As a part of the process, administrators can assist their workers in becoming more poised by praising them when possible. Managers and professionals with de facto power should also treat their subordinates with respect and let them know that their work is valued. By taking these steps, the leaders will help their more vulnerable staff members to develop a sense of self-worth (Newman, 1993, p. 1489). At the same time, supervisors need to create and maintain office environments that are as free as possible from discord—and especially from bullying. Staff should focus on lifting each other up instead of tearing each other apart. This type of culture allows everyone and not just the most aggressive or outspoken people the chance to enhance his or her self-esteem (Bowes, n.d.; Williams, 2011).

5.8 Structured Autonomy Is a Necessary Aspect of a CI-Supportive Culture

An office-level healthcare leader who wants his or employees to adopt and use CI methodologies will find the going easier if the staff possess at least a limited amount of autonomy. As I noted earlier in the chapter, individuals who have some control over their work routines might, over the long term, be more productive. At the same time, these people may have more opportunities than their micromanaged peers to develop their critical thinking skills (Snyder & Snyder, 2008, p. 93; Wilson, 1998, p. 34). This is important because workers need to be able to identify flaws in processes and suggest improvements to these systems in order for them to fully utilize CI philosophies such as Lean and Six Sigma (Pojasek, 2003, pp. 86, 88, 90; Sherwood & Jones, 2013, p. 504; Wyrick, n.d.). At the same time, staff members who have some freedom to control their job tasks are more likely to exhibit high morale and be engaged while at work. I mentioned earlier in the narrative that an organization needs to contain a critical mass of contented and engaged staff members in order for it to incorporate CI principles into its workplace (Smith, 2016).

Although office-level healthcare leaders should allow employees some autonomy in handling their daily tasks, these administrators cannot always let their workers have free reign. In many situations, individuals have to do things in a certain prescribed way in order to provide the highest quality patient care or to meet productivity-related goals. For instance, few managers or profes sionals with de facto power would allow their clinical staff to take actions that go against best practices standards. At the same time, administrators must ensure that their subordinates follow certain protocols with regard to billing, managing patient records, adherence to contracts, and so forth, in order to meet regulatory or accrediting guidelines.

With that fact in mind, I believe that office-level healthcare leaders should allow employees to act with structured autonomy. Following this logic, supervisors let their staff members have freedom of decision whenever that is possible. However, they require these people to stick to “the book” when best practices literature, corporate requirements, regulatory bodies, or common sense calls for it. In this way, healthcare administrators who want to utilize CI methodologies get the best of both worlds. Their workers benefit from having some autonomy, yet these individuals strictly adhere to predetermined protocols when necessary.

This concept is not new. In fact, most readers would consider the use of structured autonomy to be a common-sense management practice. However, in my experience, although most administrators say they support this type of workplace environment, many of them fail to promote an office culture that espouses the ideals of structured autonomy. Instead, these supervisors either spend too much time micromanaging employees, or they allow their staff members to exercise an inordinate amount of freedom. office-level healthcare leaders who are committed to incorporating CI philosophies into their workplaces must strive to find the Goldilocks zone between overly restricting their subordinates’ freedom of action and giving these individuals too much autonomy. In Figure 5.1, I discuss this topic in more detail.

Office-level healthcare leaders might be better able to navigate this dilemma if they possess an in-depth understanding of each employee’s job routines. Supervisors can use this knowledge to help them determine when to give subordinates leeway in setting and managing daily tasks and goals. As part of this process, administrators should personally analyze each job and, with relevant staff input, update position descriptions on a routine basis (e.g., at least every couple of years or when some aspect of the job changes) (Fallon & McConnell, 2007, pp. 116–118, 228). Too often, busy department heads ignore this task; they instead rely on outdated job descriptions, which they inherit from the previous supervisor (Tyler, 2013). As a key part of the job-analysis process, administrators should note which aspects of the position require strict adherence to certain protocols and which ones do not. They should then sit down with each employee to make sure that the individual understands when he or she can exercise task-related liberties. If office-level healthcare leaders perform these actions, they will stand a better chance of fostering departmental environments that promote the right amount of structured autonomy.

Figure 5.1 As the graphic demonstrates, office-level healthcare leaders can benefit when they ensure that their employees have just the right amount of work-related autonomy.

Healthcare administrators can take a number of additional actions, not only to ensure that employees have ample autonomy but also to encourage these people to use that freedom. I touch on some of these strategies in other areas of this book, so I will only mention them here. First, managers and professionals with de facto power should create office environments that allow their staff members to develop a sense of self-confidence. In my experience, self-assured individuals are more willing to use their job-related freedoms. At the same time, supervisors must not penalize their subordinates for trying something new and failing at it, as long as these individuals do not break any rules or violate ethical principles. As Alan Murray, the author of a popular business book, notes: “Unless people feel free to make mistakes, they will not feel free to take bold actions” (Murray, 2010, loc. 1286). Finally, office-level healthcare leaders must ensure that workers use software and hardware, which allows these individuals to maintain some operational autonomy. From what I have seen, an authoritarian health information technology (HIT) that controls an employee’s every move is almost as a bad as a tyrannical administrator.

5.9 Satisfied Employees Are Critical to the Success of CI Initiatives

In Chapter 4, I demonstrated that a healthcare organization needs to possess a relatively contented workforce if it wants to incorporate CI ideals into its infrastructure. Specifically, I noted that satisfied employees are more likely than their disenchanted coworkers to take active roles in CI endeavors (Landry, 2000, pp. 167–168; Sykes, 2001, p. 32). They also tend to be more willing to accept CI-related changes in their work routines (LaMar & Laney, n.d.; Landry, 2000, pp. 167–168). Finally, in my experience, happy staff members are more apt to become CI cheerleaders and champions who make an effort to convince their coworkers to adopt relevant CQI methods.

A large number of factors might impact an individual’s happiness with his or her workplace. As such, an office-level healthcare leader will not likely be able to influence all of the variables that affect the staff’s contentment levels. At the same time, an administrator does have a significant amount of control over these measures. In Chapter 8, I discuss this topic in more detail and suggest methods that supervisors can use to maintain high employee satisfaction rates.

5.10 Motivated Workers Are a CI-Focused Administrator’s Most Important Asset

More than anything else, an office-level healthcare leader needs to possess a key group of motivated employees if the administrator is going to be successful in incorporating Lean, Six Sigma, or other CQI systems into the department’s operations. Earlier in the chapter, I highlighted some of the ways in which disengaged workers can hinder or even stymie CI initiatives. By contrast, a supervisor can lean on his or her motivated staffmembers to help achieve CI-related goals. Assuming that the administrator can convince his or her energized subordinates to buy into CQI philosophies, they will often work hard to learn and utilize these methodologies (Morgan, 2015; Upshaw, Steffen, & McLaughlin, 2013, p. 293). In my experience, engaged workers will also be more likely to volun teer to sit on improvement teams. From what I have seen, they will be more apt to alert management when they espy process-related inefficiencies or other problems that are amenable to CI-related solutions. Additionally, individuals who are excited about their jobs will be less willing to resign, and on average, they will miss fewer workdays (Connolly, 2012, p. 48). Readers can readily see how these employee-related behaviors will benefit administrators who want to undertake CI initiatives. Finally, if a critical mass of staff members is highly motivated to perform CI-related tasks (or any other job for that matter), their enthusiasm will tend to have a positive impact on everyone else in the office (Friedman, 2012). This means that people who are somewhat apathetic or disengaged might work a bit harder on CI projects than they otherwise would have done.

Ideally, a healthcare administrator would like for every employee to be engaged; however, that is rarely the case. An office-level healthcare leader does, however, need to ensure that a sizeable portion of workers are properly motivated. A supervisor can utilize a number of strategies to help him or her achieve this goal. I will discuss this topic in more detail at a later point in this book.

5.11 Team Players Are an Integral Part of Any CI Strategy

If they successfully want to incorporate Lean, Six Sigma, or other CI philosophies into their infrastructures, large healthcare organizations (such as hospitals) often must be able to create and nurture in-house teams of employees who work to identify and solve operational and patient care–related issues. Members of these groups need to be able to cooperate with one another as well as with coworkers in order to perform CI-necessary tasks, including collecting and analyzing data, positing solutions to process-related problems, and overseeing the implementation of these initiatives (Sollecito & Johnson, 2013a, pp. 12, 40). Even in cases where only one individual handles a CI-related project, he or she will still need to elicit the help of coworkers to complete certain portions of this plan. Regardless of how many people work to develop and implement a CQI initiative, the staff in affected departments will likely need to cooperate with each other in order to ensure the project’s sustained success. In short, CI-supportive office cultures, whether at large institutions or small resource-challenged firms, need to promote ideals of teamwork and comradery.

Given the emphasis that CI philosophies place on interactive office behaviors, healthcare administrators ideally want to ensure that most of their employees have the necessary skills and temperament to succeed in team-focused environments. At the very least, supervisors must make sure that all of their workers are capable of cooperating with CI analysts and improvement specialists. This is the case even if their staff members’ typical job tasks do not require these individuals to collaborate with others. Department-level healthcare leaders can accomplish these goals via utilizing one-on-one management strategies and by helping to foster cultures that encourage participatory mind-sets.

5.11.4 Keeping Track of Workers’ Team-Related Strengths and Weaknesses

Teams should comprise individuals with a diverse array of personalities, skills, and backgrounds in order to be most effective. At the very least, the groups need to include people whose abilities complement those possessed by their teammates (Buchbinder & Thompson, 2012, p. 288). With these facts in mind, healthcare administrators must be cognizant of their staff members’ strengths and weaknesses so that these leaders can create the best intradepartmental squads and assign the most competent employees to work on interdepartmental task forces and committees (Buchbinder & Thompson, 2012, p. 288).

Given the importance of teamwork in today’s healthcare workplace, I believe that administrators should make it a point to assess each employee’s key attributes as they relate to his or her ability to work on collaborative projects (both CI-related ones and other types). The supervisor can create a document to keep track of this information. The office-level healthcare leader does not have to use anything elaborate; he or she can posit the data on a simple chart or diagram. The manager or professional with de facto power can review this material when it comes time to provide extra training for staff, to designate individuals to serve on an intradepartmental collaborative project, or to assign workers to an organizational-level CI task force or committee. Readers can refer to Figure 5.2 for an example of this type of form. As with all other employee-related information, the administrator should take safeguards to keep this data private.

Figure 5.2 Office-level healthcare leaders can utilize a simple diagram or chart, like this one, to help them keep track of each employee’s team-related abilities.

5.13 Trust: The Glue That Holds Every CI Project Together

From what I have seen, in order for a healthcare supervisor to incorporate Lean, Six Sigma, or other CI methodologies into a department’s routines, that person must engender his or her employees’ trust. More specifically, the workers need to have faith in their administrator’s words and actions. Additionally, they must believe that he or she is putting the CQI system in place for the right reasons. In my experience, if staff members trust their leaders and believe in the organization’s ideals, they will often be willing to give CI techniques a try despite any anxieties or doubts that they might personally have about these processes.

Personally, I think that the best way for office-level healthcare leaders to earn their employees’ trust is to act with veracity and treat employees with respect and dignity. It goes without saying that administrators who strive to maintain a high degree of integrity in their work-related interactions are more apt than others to garner the faith of their staff. Most readers would also probably agree that managers and professionals with de facto power can build bonds of trust with subordinates when they treat these people with respect and kindness. As part of this process, supervisors need to cultivate departmental environments that are built on mutual admiration. Finally, healthcare administrators must have had some success when it comes to implementing process- or service-related improvements (Bews & Rossouw, 2002, pp. 378–379). After all, who would trust someone who says, “These changes will enhance patient care in this unit,” if all of the individual’s previous initiatives have failed?

5.14 Employee Adaptability: Critical to the Success of Many CI Implementation Strategies

As I have noted previously, healthcare administrators will often need staff to alter their established ways of thinking or acting in order to integrate CI philosophies or initiatives into the workplace. For instance, these leaders might have to ask employees to make significant adjustments to their work habits or behaviors in order for the department (or organization) to implement CI-related improvements. At other times, supervisors may disrupt office protocols and routines when they attempt to incorporate CI methodologies into their unit’s standard operating procedures (Breland & Newton-Ward, 2013, pp. 231, 239; Sollecito & Johnson, 2013a, pp. 6, 8). Healthcare managers and professionals with de facto power will have a difficult time implementing CI-related elements into their departments if their staff refuse to make the necessary workflow-related changes.

In some cases, an office-level healthcare leader might have little or no say in deciding whether to require employees to change their work routines to accommodate a CI-related initiative. At least in my experience, it is common practice in some companies for executives to decide which projects or strategies move forward (often without fully vetting the proposed alterations with frontline managers). Regardless, the healthcare administrator must play his or her part in convincing staff to make any necessary adjustments to workflows in order to accommodate CI-related process improvements. Ideally, a manager or professional with de facto power will oversee people who are eager to make these alterations. However, in reality, the opposite situation is more often the case. In either event, a healthcare supervisor needs to be cognizant of the staff’s attitudes towards workflow-related alterations so that he or she can create a solid strategy for getting these people to buy into any CI-related adjustments. Administrators can use a chart that is similar to the one in Figure 5.3 to help them assay their employees’ change-related tolerance levels.

Figure 5.3 Administrators can use forms like the one above to help them collect and analyze data relating to their employees’ tolerance for change.

If an office-level healthcare leader is committed to incorporating CI techniques into his or her department’s operating procedures, that person wants to foster a culture that is supportive of CI-related changes. As part of this process, the administrator will want to know what each employee’s tolerance to change is, so that he or she can work with these staff members on an individual basis to encourage them, when appropriate, to adopt new or altered work routines. As a first step, the manager or professional with de facto power can use a form like the one in Figure 5.3 to collect pertinent data on his or her employees. The supervisor can then use basic mathematical and statistical methods to analyze this information.

5.15 Additional Employee-Related Skills That CI-Focused Administrators Should Covet

Earlier, I delineated some of the traits that employees who work in a CI-supportive department should possess. I want to quickly list some additional staff-related attributes that CI-focused administrators should covet. They include:

• Abstract Thinkers: These employees are able to analyze systems, issues, and ideas at their most nonconcrete levels. Abstract thinkers might not be as good as others when it comes to “getting in the weeds”; however, they are adept at identifying systemic flaws and in creating big picture strategic plans. Every administrator wants to have at least one of these staff members in the office.
• Math and Statistics Mavens: In many departments, staff do not need to know much about math or statistics to perform their jobs. However, all administrators, assuming they are not quantitatively inclined, will be better offif they have one or two math and statistics mavens on their payrolls. For one thing, a person who possesses these abilities will be an asset to almost any CQI team. At the same time, this employee type can help his or her supervisor to craft CI-related strategies and analyze collected data.
• Technophiles: office-level healthcare leaders who are committed to CI can benefit from having a technophile on staff. That individual can serve as an HIT champion who can convince coworkers to adopt new software and hardware systems.
• Good Writers: If an office-level healthcare leader is not a good writer, then he or she should make sure to employ an individual who possesses this skill. People who are capable wordsmiths are able to create messages, memos, and other documents that are coherent and organized. Anyone who has worked in healthcare knows the value in being able to communicate with staff in a clear and direct manner. Managers or professionals with de facto power can rely upon their writing gurus to help these leaders successfully disseminate CI-related information to staff.

5.16 Summing Things Up and Looking Ahead to Chapter 6—A Guide to Implementing and Monitoring Quality Improvement Initiatives

In order for a healthcare organization to incorporate CI methodologies into its operating structures, it needs to ensure that each departmental culture is supportive of CI philosophies. To help prove this point, I begin the chapter by highlighting some of the ways in which a dysfunctional office environment can hinder CI initiatives. I discuss some of the important aspects of these departmental (and firm-level) cultures and demonstrate why they often impede the ability of executives and administrators to integrate CQI techniques into the workplace. I then pivot and review the key elements that are part and parcel of CI-supportive office environments. As part of this process, I argue that these places contain a critical mass of employees who possess certain abilities and mind-sets. I devote time to each of these staff-related talents or perspectives and provide healthcare administrators with tips on how they can help their workers to develop these traits. I end the chapter by delineating some employee-related attributes that CI-focused managers should covet but do not necessarily need.

In the next chapter, I provide readers with some suggestions on how to implement and monitor quality improvement initiatives in an office setting (or perhaps even organization-wide). I focus special attention on the needs of managers and professionals with de facto power at small or resource-challenged institutions. I first posit general tips that a healthcare administrator can use to improve his or her staff’s operational efficiency and effectiveness. For the remainder of the narrative, I proffer strategies that a supervisor or analyst can utilize to identify problems, get stakeholder buy-in, and craft sustainable CI-related solutions to these issues. I will add anecdotes from my work-related experiences to help illustrate many of the key points in the chapter.