A wanderer asks a woodcutter in the forest the way. The woodcutter says that he has so much to do that he has practically no time for explanations. The wanderer then asks him if he has ever thought to sharpen his axe. To which the woodcutter says that he has so much to do that he has absolutely no time for that sort of thing. (Anon.)
A typical situation associated with the optimisation of processes in a hospital or a practice is as follows: Staff members are asked whether they would like to take part in a working group / workshop. Everyone knows that this will be in addition to daily tasks. The answer is: “Can’t do that now — too much pressure of work — later, perhaps”. If the employee is nevertheless selected for the task, he or she will try to ‘survive’ this working group or workshop with the least possible effort, or cause it to fail by increasing the degree of complexity. If such employees are also senior managers of staff, this has an especially limiting effect on the organisation’s development potential.
Attempts to achieve successful organisational development often fail. Anyone who has held workshops with unprepared and unwilling participants, complaining that they are losing time they need for their ‘real’ work, will already know some of the causes.
Reasons for Failure
1.Not ‘tried and tested’, doubting Thomases: Senior managers cannot be persuaded of the need to depart from ‘tried and tested’ procedures and privileges. Everything seems fine on their ‘island’ (eg full complement of staff, an acceptable balance between pressure of work and salaries, sufficient (private) patient numbers). Then there are strategies and concepts for change that are presented by senior managers, who do not believe that they can be implemented. The defenders of vested interests, the doubting Thomases and the pessimists take the helm!
2. Always done this way: N ew c hallenges require new processes, structures and modes of thought. However, senior managers try to solve today’s problems by using yesterday’s methods (“We’ve always done it that way.”) The old way, with well-known structures and procedures, achieves more individual performance while maintaining quality and using existing equipment and rooms, but fewer staff. generally, this ‘prescription’ leads to failure and frustration. The old structures are already at their limits; all room to manoeuvre has long since been used up.
3. Stick to specialty: Top level and senior staff often seek refuge in operative activities related to their specialities (‘safe ground’ — That’s what we have been trained to do, that’s why we became doctors, administrators etc.), either because they are afraid of the strategic challenges involved in developing processes, structures and staff, or they do not like that kind of work. Organisation of procedures and structures in hospitals and practices is accompanied by unrest and scepticism, and invites resistance: not many people wish to take such things upon themselves.
4. Social and leadership skills not integrated into change strategy: There is no systematic and sustainable process for developing the social and leadership skills of present and future senior managers. For example, a ‘Leadership Workshop’ organised by the human resources department and presented by external experts (“You’d better go along, too”), is not backed up by a sustainable change strategy (monitoring, systematic refresher courses) with an assessment of results. Isolated courses for senior managers that are not integrated into a change strategy for existing processes and structures (eg for reporting structures and hierarchies) are pointless and useless, as what is allowed is not in line with the knowledge that has been amassed and the will to implement it. It is often not clear where responsibility for senior staff development lies.
5. Change management is a n ‘addon’: There is no professional, systematic change management. Change management is not an ‘add-on’ task to be addressed at the end of a busy daily routine, but the main task for qualified,specialised, additional staff. Often, the way things develop and the results achieved are not properly monitored and weak points in management remain unaddressed. This is when the PDCA cycle (plan-do check-act) has no effect outside management seminars. If these issues are not addressed professionally, sustainability falls by the wayside, and in a short space of time things are back to square one.
6. Information dissemination is poor: The medium and long-term targets of the hospital may be discussed at great length by senior management. However, this does not trickle down to other employees, despite general statements distributed via newsletters, information meetings etc. (Lack of feedback on the quality of the information management.)
7. Stick to the familiar: Where defenders of privilege and doubters rule, there is no room for clear decisions that lead to definite consequences — rather stick to the familiar (and hopefully improve it a little).
8. External consultants are hired: When things have to change, external consultants are called in to supply the missing competence in an environment they do not know well, and for which they cannot be well prepared. Someone who does not have the capacity to introduce and implement change generally also has no capacity to put systematic monitoring in place to ensure sustainability (processes, structures, persons), and does not have to communicate uncomfortable news personally.
9. New processes and structures slotted in: Persons have to adapt to (be selected to fit in with) the necessary (new) processes and structures. Often, processes and structures (and implicitly the patients) are adapted to the people who are there already.
Figure 1. Problems and Hazards of Project Management
Successful optimisation takes place in the following order: first the processes, then the structures, then the staff need to adapt/develop.
Following a laborious learning curve consisting of the failed experiments of the old guard of senior managers, leading to no change in the processes, structures and staffing, new senior managers are appointed. They put everything that has been learned into question, and the cycle begins anew. New senior managers are given the brief to improve what is already there. However, when one turns 180o, and does the same thing again, one ends up pointing in the original direction.
Examples for this are:
• The introduction of treatment paths (no sustainability);
• The introduction of new, interdisciplinary and autonomous centres with the aim of optimising overall processes across departments (new name in old responsibility structures);
• Certification (ever ything gets described, nothing gets done);
• Systematic, multi-project management, transparent for all employees (soon forgotten after the end of a workshop);
• Internal cost allocation for performance items (brief attempt to optimise costs without evidence of sustainability);
• Budgeting on diagnosis-related group (DRg) shares (short-term attempt at implementation after a workshop);
• Systematic personnel development (uncoordinated individual measures without overall plan).
If you enquire into the result of a workshop not only immediately afterwards, but a year later, often nobody can remember the workshop and the results have been forgotten. However, nobody has noticed this, because by good luck the economic results have improved again, so there is no more pressure to act. When strategies that have been agreed fade from memory without consequences, this represents a poor basis on which to build future developments.
Within existing structures, the ‘energy’ of a hospital is still sufficient for individual measures (workshops, seminars). However, sustainability can only be guaranteed through integration into a long-term concept with regular monitoring and refreshment, as well as personal responsibility. Optimisation of processes and structures must be carried out on time and with considerable organisational effort.
Tips for Success
• As a manager, clarify how things stand with your capacities, your wishes and what you are allowed to do before starting a task! When senior managers are commissioned to undertake tasks and projects, often the framework conditions are not sufficiently defined and discussed, perhaps because they are not clear to whoever issues the commission. No project work can be successful where the prerequisites and framework conditions are unclear and insufficient time is allocated.
• Where strategic thinking is missing, workshops with external experts are rarely useful. Workshops are a (useful) part of operative business, not of strategic planning.
• Working in projects requires future project leaders to go through a learning and practice phase. Successful project managers must have methodological, subject-specific authority and maturity of outlook. in order to inspire confidence in the participants.
• Project managers should be versed in the ‘art of red lights’ - with experienced project managers, these light up at a very early stage when there is a danger of things going off course. Then, it will be necessary to conduct time-consuming personal individual interviews, perhaps to pinpoint personal points of sensitivity. This requires experienced project managers with authority.
• It is better to pass up a task at an early stage rather than try to execute it when one already knows that it will not succeed.
In poorly managed organisations it is still possible to get away with: “Say yes and do nothing — sooner or later it will be forgotten.” That does not work in a well-run organisation. Another tactic used by unwilling participants is to engineer a rapid increase in the degree of complexity involved so as to render the project task impossible. In such cases the project manager should concentrate efforts strictly on what is essential if necessary using a dose of authority.
Tips for Project Managers
To conclude, the author would like to present examples, hints and tricks gathered over 25 years of personal experience for discussion and as a stimulus.
• Address employees in their (mental) situation as it actually is, not as it should be.
• Don’t overestimate the available social and managerial competence.
• Take account of individual egoism on the part of the participants (“What’s in it for me?”).
• Don’t rely on information being passed on properly (use smaller information units). You can only rely on rumours and scandals being passed on faithfully!
• Without systematic repetition (practice) and regular monitoring information is quickly forgotten. If there is not enough energy available to push things through (processes, structures, staf f ), then don’t even start!
• Take a lot of time for personal conversations.
• Make sure that a positive climate of change is there before the workshop starts.
• Try to make sure that nobody is seen to be the ‘loser’ of a conflict.
• The ‘face-saving’ part of the task is often the most difficult, but it ensures that there are no open sores and enmities afterwards.
• Never take important decisions spontaneously (think it over first — sleep over it at least once).
• Before drawing conclusions and making decisions, first check the quality of the available information.
• When a problem presents itself, make an assessment of its significance and effects. When assessing problems, be aware of the difference between the volume of the cheese and the volume of the holes between! Don’t spend disproportionate amounts of your time on organisational rarities (first draw up a statistic — and remember the Pareto principle). Then either solve the problem or ignore it steadfastly.
• Don’t allow every problem to find its niche on your back!
• Delegate and monitor — although the responsibility remains yours.
• Don’t forget anything (use IT tools or at least a note on your desk).
• Don’t start a working group for reasons based on your own strategic and operative helplessness. Talk t o e ach p articipant i n advance (and privately) and make sure of his or her competence and motivation.
• Formulate initial, clear targets and framework conditions in writing that are not subject to debate.
• Bring order into your dealings that is visible to others. (Sometimes a desk is a mirror of the head that owns it.) Senior managers are responsible for the way the department and the staff present themselves to the world. Quality must be made visible through an attractive ambience.
• A key organisational factor is a visually appealing reception area staffed by very competent people and always ‘open for business’. This makes for a good atmosphere prior to diagnosis/therapy, and represents a useful pre-emptive defence against complaints and legal disputes.
• Live out what you demand of others!
• organisational development in hospitals and practices of ten fails.
• Explores the human factors behind this failure.• Tips for success and tips for managers in project management.