We were in the final stages of completing this manuscript when Covid-19 jumped from a shadow to an international pandemic, upending lives around the globe, creating heroes out of healthcare workers everywhere. Physicians and nurses came out of retirement in New York; obstetricians in Wisconsin scrounged up protective gear to help in the intensive care units (ICUs). Family doctors staffed rapidly constructed respiratory centers and, every evening in major cities around the world, people went out on their balconies and cheered for the healthcare workers that were risking their lives to save us.
What do we owe them, those frontline caregivers who donned hazmat suits and reused n-95 masks and dragged themselves to the emergency room for another 16-hour shift, day after night? Certainly, we have all learned the importance of keeping an adequate supply of personal protective equipment (PPE). We know now, with the clarity of a slap in the face, the problems inherent in the for-profit supply lines that surround our non-profit hospitals. Some of these issues will need to be corrected at the national level.
While we celebrate heroes, we cannot demand this of people. We cannot ask people to put themselves in harm’s way unless we are willing to work alongside them, improving their ability to provide care while keeping themselves safe. This book is about the efforts of healthcare organizations around the world to do just that. It is about leaders who are confronting their own gaps and undergoing personal change in order to better support the frontline. We cannot imagine a more important message at this critical juncture.
"I know I need to change. But how?"
The voice of the chief medical officer over the telephone was tight and unhappy. After 15 successful years as a medical specialist and another three years in leadership at this 500-bed American hospital, she was not used to stumbling on the job. She had gone to all the best schools and, in her experience, solutions were almost always within easy reach.
Now we were asking her to look at her hospital units in another way. Specifically, we were asking her to look without talking, without offering solutions. It was so much harder than she thought.
Like many doctors of her era and training, she was taught to take control of situations. If someone had a question, she liked to say, she had the answer. And because she always delivered that answer with a smile and a sense of camaraderie, people loved her.
Yet every day, this CMO left the hospital not knowing what she did not know. She knew there were problems of unknown origin and that she talked more than she listened. She wanted to change, she told Kim. The idea of learning from front-line medical staff about their problems made perfect sense. But how do you change decades of training?
So, a few weeks later, Kim arrived for a visit and went to gemba with the CMO to observe her in action. The CMO’s first job in this personal coaching session was to observe a nurse going through the process of discharging a patient from the hospital. The CMO notified a nurse in advance that they would be observing the process in order to learn — not judge — and then listened as Kim listed the rules.
The CMO should ask no questions unless she saw something that was clearly putting the health and safety of a person at risk. If that happened, the gemba visit would be suspended while the situation was corrected. Otherwise, no questions. If the CMO could not help herself and absolutely had to speak, she was given a list of four acceptable questions that were focused on the purpose of the work. The CMO nodded; she was ready.
On the medical-surgical unit, a patient’s lead nurse handled all the administrative and quality checks to be completed before a patient left the hospital, such as ensuring necessary testing had been performed, follow-up appointments had been scheduled, and prescription medications dispensed.
In this case, the lead nurse was off shift and so the role fell to a nurse unfamiliar with the patient. The fact that he was being watched by the CMO and Kim probably made the nurse even more careful. He seemed determined to check every bit of information twice. But just as he confirmed that one test was done, a colleague alerted the nurse that he was getting a new patient. He left to complete that admission process, then returned and was interrupted again with questions about another case.
Still, this nurse diligently stepped through the discharge process, trying to get a patient safely home and free up a bed.
"Are you going to call the pharmacy and see if his prescriptions are ready?" the CMO asked.
The nurse nodded, interrupted his current task, placed that call and continued on. Placing that call to the pharmacy was on the nurse’s list, he just had not arrived there yet.
Back in the CMO’s office, Kim asked how she thought the observation had gone.
"Why do you think the discharge process took so long?" the CMO asked in return. "We really need to streamline that process."
"Well, part of the problem may have been that the nurse was interrupted 13 times," Kim said. "And five of those times were by you."
We begin with the story of this observation because moments like this are the raw material that culture is made of. We can make all the announcements that we like about transformation and organizational excellence, but none of it is real until leaders exhibit the behaviors that align with their words.
If a leader says she is there to observe and ends up directing the action, we know there is another agenda.
No matter how warm and personable this CMO was, every time she reminded the nurse to do a bit of work, she was saying that she knew the process better than he and that she was watching for compliance. And so they remained locked in their old roles: the know-it-all boss, the subservient underling.
This is a dynamic we have seen play out dozens of times and it has led us to a simple lesson: Motivations matter and, at gemba, people can see yours.