Many contemporary management approaches call for an increase in transparency in the activities of management and staff; AAHA has followed suit in their Standards. I have found practices opening their P&L to staff (TMI = too much information), as their interpretation of transparency, so that is the reason for this review.
This is a dramatic shift from the days when the carrot-and-stick approach to management was the executive’s most reliable tool to move an organization and staff forward (also entrenched in most Veterinary Teaching Hospital cultures). But how much transparency is needed, and at what point can such transparency compromise the veterinary practice in terms of its competitive position – or its liability exposure? How will efforts in transparency be rewarded for the practice owner who has the courage to become the champion for change? The numerous issues that come to bear on this matter call for leaders to approach transparency with caution, diligence, and ultimately, compassion.
Embracing transparency enables a practice to conform to market expectations while satisfying the demand for client/patient confidentiality. However, there’s a better reason to make this commitment. The single greatest argument for increased transparency is that it reveals improvement opportunities in the practice’s healthcare delivery systems. If the management of a practice do not identify these opportunities, they risk a false sense of security and a blind spot to emerging threats. A practice that fully embraces transparency can undertake the important work of performance improvement – not only doing things right, but doing the right things with a continuous quality improvement (CQI), and clear Standards of Care (SOC) as well as inviolate core values. To do this, practices need new metrics – not based on dollars, but rather, based on patient needs and booking for specific procedures per 100 transactions.
Unfortunately, many veterinary software systems, and practice cultures, are not prepared for the shift to transparency. Transparency exposes both good and poor performance, and staff who fear punishment will not readily heed the call for increased reporting of performance measures. Moreover, key providers may be reluctant to expose their peers if it leads to scrutiny of performance (e.g., number of booked dentals per 100 patients seen). How do healthcare leaders overcome these barriers?
A PROTOCOL FOR TRANSPARENCY
The journey to transparency begins with leaders recognizing, and subsequently convincing the staff, that it is about the process, not the people. Management must begin with the premise that the practice team does not intentionally produce poor results. Reckless staff are easy to find and dismiss; no one hires for ineptness. Performance of other team members may be limited, in varying degrees, by the design of the practice’s organizational, operations, the lack of a current in-service training system, physical limitations, or unreal expectations before competency is achieved. Only when system flaws are identified can management repair them, and only when human errors are discovered can management assist people to cope with, correct, and avoid similar errors in the future. To make these discoveries and to understand what to fix, management must leverage the knowledge of the practice team closest to the work and the processes.
One might be tempted to dismiss this advice as a case of “easier said than done”. However, many organizations, and a few veterinary practices, embrace Greenleaf’s servant leadership principles, and the one’s that do, find that transparency is aided by adopting a “just culture”. The term just culture, coined by British scholar James Reason, refers to a culture that embodies the following assumptions and conditions (as modified for a veterinary practice):
- Management is responsible for providing the systems and structure for the team to accomplish their work.
- Management and staff come to the work environment with different values and expectations. Managers expect the staff members to perform according to the practice’s core values, standards of care, and expectations for excellence in client service and patient advocacy. Managers expect staff to perform according to training and protocols, and the staff reasonably expect systems to support their performance and quest for excellence.
- Staff members are presumed to be well-intentioned, but they may occasionally drift from the standards of practice. When errors are discovered, they can be categorized as human error, at-risk behavior, or shortfalls in training (a servant leadership approach starts with the premise of a training shortfall).
- Human error and at-risk behavior often provide important clues to system improvement opportunities. When people feel safe to report findings that reveal these improvement opportunities, the practice team can quickly address challenges, prevent recurrence, and boost performance.
A properly implemented ‘just culture’ program will require managers and staff to openly discuss the discovery of any breach of practice standards or organizational behavior.
An algorithm that addresses the following questions is applied to the situation being examined:
- Did the individual intend to cause harm?
- Did the staff member knowingly and unreasonably increase risk?
- Would another similarly trained and skilled staff member, in the same situation, act in a similar manner?
- Did the social benefit sought by the staff member legitimately outweigh the attendant risks?
- Did the patient or client suffer because of the situation?
- Did the staff member understand the “mission focus” of the practice?
SAMPLE OF MISSION FOCUS STATEMENT
Client-centered Patient Advocacy
To Enhance and Extend
The Quality and Duration
Of an Animal’s Life!
Extracted from VCI “Winning Way” Pocket Card
Although the inquiry focuses on the staff member’s behavior, a servant leadership approach takes great care to reveal the system’s own contribution to the short-fall. Inevitably, the process of inquiry works when the parties reach a better understanding of both individual and organizational behavior expectations, including the value of Core Values being inviolate as well as a “safe haven” for well-meaning independent actions. The key action is the joint commitment for assessment of system requirements and expectations for operational improvement. All parties win when a process such as this replaces the arbitrary quest for assigning blame, or other traditional forms of reward or punishment.
MISSION & VISION NEED TO BE PERFECTLY CLEAR
Establishing the return on investment from a practice philosophy, such as transparency or servant leadership, may be difficult, depending on the practice culture.
As a sidebar – practice culture is often a major change management direction for many of my consults. The benefit of transparency and servant leadership by management is in the avoidance of risks with uncertain probabilities. The practice of transparency in current non-healthcare organizations now comes with enterprise risk management (ERM), and failure modes and effects analysis (FMEA). Fancy terms for awareness by a savvy servant leadership practice culture.
Some hospitals put transparency procedures into an option of anonymous reporting of errors and near misses in medication administration. The rate of medication errors skyrocketed over 100 percent in just in a few days. Once it was put into proper context. The medical staff felt compelled to report concerns when the fear of punishment was removed. It was suspected all along that there were more errors and process issues than being reported, and the transparency effort proved they were right. Then management could actually begin the work of improving the medication protocols.
TAKING THE BLINDERS OFF
Practice leadership might find that increased transparency reveals things about their practice that they didn’t necessarily want to know. Some findings can be alarming, and it is best for the management to be prepared to devote serious attention to the process and what its outcomes suggest about the quality of care practiced within its walls. Current human healthcare terminology dictates:
- COMPLIANCE = actions within the practice by staff and management
- ADHERANCE = actions by clients/patients based on healthcare advice
In his song “On the Road to Find Out”, Cat Stevens laments the fact there is “so much left to know,” but realizes that “the answer lies within.” Transparent organizations have shown they are able to reap tangible rewards because the servant leadership culture has the courage to look within and resolve to do something with what they discover. Concurrently, the “blame game” ceases to exist, and the Core Values provide a ‘safe haven” for independent decisions by the staff with well written Standards of Care and Mission Focus.
In veterinary practices, we are in a unique position of having leadership and staff involved because most of them are in their positions because of the “calling” to tend to the critters (ergo, the MISSION FOCUS example shared earlier). When that “mission focus” is laid over any healthcare program, it should show that the decision(s) are based on quality care principles and practice, and if not, the program must undergo revision to ensure wide acceptance by staff and clients alike.
Transparency will become the new normal in healthcare operations, and savvy leaders would be wise to get the process started.