By Paul Levy

First Posted at Athenahealth on 5/28/2013

Paul Levy, Host of (Not) Running a Hospital

Paul Levy, Host of (Not) Running a Hospital

When things go wrong in a hospital—on either the clinical or administrative front—we are often left wondering how a dedicated and thoughtful team of people could have jointly participated in the decisions and actions that led to the failures. Recent stories in the news may give us a clue.

Problems recently uncovered at the Internal Revenue Service are typical of those found in many organizations when a team of people become isolated and feel unsupported. The team might be doing a job that nobody else wants to do or is out of the mainstream, work often characterized by a large number of repetitive tasks. Things appear to go well for a while but then take a turn for the worse.

In a Harvard Business Review article I authored in March 2001, I named this syndrome “The Nut Island Effect.” I told the story of a team of skilled and dedicated employees working at the Nut Island sewage treatment plant who became isolated from distracted top managers, resulting in a catastrophic loss of ability to perform an important mission, preventing the pollution of Boston Harbor. The irony was that from the outside, the team had all the attributes of an ideal working group: dedication, collaboration, a strong sense of integrity and values, and indefatigable energy with regard to doing the job.

The employees at Nut Island had set up their own team without the direction and guidance of management, and it had become a priority among the group to avoid contact with upper management whenever possible. Indeed, they viewed senior management as a common adversary.

In the world of Washington politics, there is a tendency to blame the front-line staff… the same tendency often exists in the health care world.

This isolation led to a lack of accountability with regard to the strategic objectives of the agency. It also precluded an infusion of new ideas and approaches, so that the group began to make up its own rules. The rules, though, were insidious because they fostered within the team the mistaken belief that its operations were running smoothly. Yet, the rules actually resulted in improper operation of the plant and increased pollution of the harbor.

In the years since publishing “The Nut Island Effect,” I have often heard from doctors, nurses, and hospital administrators who have said, “I felt like you were writing about my place! You could have written this story about my operating room (or ICU, or administrative division.)”

Look at these excerpts from a recent New York Times story, “Confusion and Staff Troubles Rife at Cincinnati IRS Office.” Then think of your own hospital and see if you might apply some or all of those descriptors to a functional area in your organization.

Low-level employees, in what many in the I.R.S. consider a backwater, processed thousands of applications a year. Inside the agency, the unit was considered particularly unglamorous. Interviews paint a more muddled picture of an understaffed Cincinnati outpost that was alienated from the broader I.R.S. culture and given little direction. There were times where staff came up with shortcuts that were efficient but didn’t take into consideration the public perception.

In the world of Washington politics, there is a tendency to blame the front-line staff in this kind of situation. Unfortunately, the same tendency often exists in the health care world. But within the IRS, as in your organization, the responsibility has to be shared with the top management.

The Nut Island story prompted me to generalize a five-step process that defines the progression from management-employee alienation to employee self-regulation of critical processes to, finally, mission failure:

1.
Senior leadership, focused on high-visibility problems elsewhere in the organization, assigns an important, but behind-the-scenes, task to a team and gives that team a great deal of autonomy. The team members become adept at organizing and managing themselves, and the unit develops a proud and distinct identity.

2.
Senior leadership takes the team’s self-sufficiency for granted. Ironically, the unit may often be viewed as an exemplar of “team spirit.” At the same time, team members are ignored when they ask for help or try to warn of impending trouble. The team feels betrayed by management and becomes resentful.

3.
As a result, an us-against-the-world mentality takes hold within the team, along with a heightened sense of being a band of heroic outcasts. Now, the team grows skillful at disguising its problems, driven by a desire to stay off the radar screen of the senior leadership. Team members never acknowledge problems to outsiders or ask them for help.

4.
Senior leadership, for its part, is more than happy to assume the team’s silence means that all is well. The team begins to make up its own rules and tell itself that the rules enable it to fulfill its mission. In fact, though, these rules mask grave deficiencies in the team’s performance.

5.
Both sides, senior leadership and the team, form distorted pictures of reality that are very difficult to correct. They shun one another until some external event, often a catastrophe, breaks the stalemate.

It is far better to avoid the circumstances that lead to The Nut Island Effect than to try fixing the syndrome after it has developed. Traditional management theory suggests the way to avoid the problem is to impose key performance indicators (KPIs) on the department, division, or group. KPIs are supposed to be reflective of the broader strategic priorities of the organization, but there are thousands of examples where the existence of KPIs has been ineffective in solving the underlying sociological problem of a good team that has gone wrong.

The ultimate way to avoid The Nut Island Effect is to foreclose the possibility of isolation in the first place. The most effective way to do this is create a culture of process improvement in which it is the management’s job to be physically present and responsive when people working on the front-line call out problems and obstacles in their day-to-day work. Management has to assume the role of “servant leaders,” in which they work for the staff and not vice-versa. This approach to the design of work is inherent in Lean but can exist in any organization. Where it does not, it is a symptom of leadership failure that will some day lead to catastrophic results.