What creates a toxic hospital culture?


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Hospital culture is largely influenced by the relationship between administrative and clinical staff leaders. In the “old days” the clinical staff (and physicians in particular) held most of the sway over patient care. Nowadays, the approach to patient care is significantly constricted by administrative rules, largely created by non-clinicians. An excellent description of what can result (i.e., disenfranchisement of medical staff, burn out, and joyless medical care) is presented by Dr. Robert Khoo.

Interestingly, a few hospitals still maintain a power shift in the other direction — where physicians have a stranglehold on operations, and determine the facility’s ability to make changes. This can lead to its own problems, including unchecked verbal abuse of staff, inability to terminate bad actors, and diverting patients to certain facilities where they receive volume incentive remuneration. Physician greed, as Michael Millenson points out, was a common feature of medical practice pre-1965. And so, when physicians are empowered, they can be as corrupt as the administrations they so commonly despise.

As I travel from hospital to hospital across the United States (see more about my “living la vida locum” here), I often wonder what makes the pleasant places great. I have found that prestige, location, and generous endowments do not correlate with excellent work culture. It is critically important, it seems, to titrate the balance of power between administration and clinical staff carefully — this is a necessary part of hospital excellence, but still not sufficient to insure optimal contentment.

In addition to the right power balance, it has been my experience that hospital culture flows from the personalities of its leaders. Leaders must be carefully curated and maintain their own balance of business savvy and emotional IQ.  Too often I find that leaders lack the finesse required for a caring profession, which then inspires others to follow suit with bad behavior. Unfortunately, the tender hearts required to lead with grace are often put off by the harsh realities of business, and so those who rise to lead may be the ones least capable of creating the kind of work environment that fosters collaboration and kindness. I concur with the recent article in Forbes magazine that argues that poor leaders are often selected based on confidence, not competence.

The very best health care facilities have somehow managed to seek out, support and respect leaders with virtuous characters. These people go on to attract others like them. And so a ripple effect begins, eventually culminating in a culture of carefulness and compassion. When you find one of these gems, devote yourself to its success because it may soon be lost in the churn of modern work schedules.

Perhaps your hospital work environment is toxic because people like you are not taking on management responsibilities that can change the culture. Do not shrink from leadership because you’re a kind-hearted individual. You are desperately needed. We require emotionally competent leaders to balance out the financially driven ones. It’s easy to feel helpless in the face of a money-driven, heavily regulated system, but now is not the time to shrink from responsibility.

Be the change you want to see in health care.



Three C’s for Listening Like a Leader


Listening is a vast ocean surrounded by empty beaches.

I’ve been paying attention to listening, both my own and others. You’re more likely to meet a red-crested tree rat* than to meet someone who actually listens.

5 reasons shallow listening is normal:

  1. Desire. Listening is such a bother.
  2. Ignorance. You might listen if you knew how.
  3. Time. Hurry up. The clock’s ticking.
  4. Energy. You don’t have energy to listen deeply.
  5. Discipline. On a list of “hard things to do,” listening is near the top.

Set the stage for deep listening:

Unfocused conversations feel like chasing chickens.

Establish conversational direction or you’ll end up exhausted and disappointed.

  1. What’s on your agenda today?
  2. What good thing might come from our conversation?
  3. What would you like to accomplish during this conversation?
  4. What’s important for you to bring up during this conversation? What’s important to you about that?

Three C’s for listening like a leader:

#1. Character.

#2. Calmness.

Breathe deeply.

Although listening takes energy, it requires a calm spirit.

Inner agitation blocks listening.

#3. Compartmentalization.

Set a fence around your listening space. You don’t have anything else to do except attend to the person speaking.

Explain time limits before you begin. Because listening requires rigor, you might need to set short-time limits.

After explaining limits, attend fully.

The character of a listening leader:

#1. Courage.

Churchill put it this way, “Courage is what it takes to stand up and speak; courage is also what it takes to sit down and listen.”

#2. Compassion.

“Compassion is the quality of having positive intentions for others. … It’s the ability to understand others and use that as a catalyst for supportive action.”**

#3. Confidence.

Insecurity seems to loosen tongues and close ears.

#4. Openness.

A closed mind lies behind closed ears.

Poor listening is a character issue.

What’s one thing you could do that would make you a better listener?


When Dying Man’s Last Wish Is Against Hospital Rules, Nurse Goes Above And Beyond To Fulfil It


Carsten Hansen’s dying wish wasn’t a complicated one. The 75-year-old man wanted to smoke a cigarette, drink a glass of white wine, and watch the sun set. His wish was, however, against hospital rules.

After suffering an aortic aneurysm, Hansen was admitted to a Denmark hospital in April. The surgery to repair the aneurysm was long and complicated, and Hansen would need to stay in the hospital for the recovery.

However, Hansen was too weak and sick to survive the surgery. Without it, he probably wouldn’t live more than a few hours, since the aneurysm had caused significant internal bleeding. Knowing that he had just a few hours to live, Hansen told nurses that he wished to smoke a cigarette, drink white wine, and watch the sun set.

Working together, the nurses found some white wine. Hansen’s hospital room had a view of the setting sun, so that part of his wish would be taken care of. Finding a cigarette proved to be a challenge, though. The hospital had a no-smoking policy to help protect its patients’ health. However, Rikki Kvist, Hansen’s nurse, decided that just this one time it would be okay to break that rule.

Nurses wheeled Hansen out onto the balcony, lit a cigarette for him, and gave him a glass of white wine. Hansen was able to watch the sun setting with his family.

According to Kvist, the atmosphere was a relaxed one. Hansen’s family was doing their best to cope with the fact that he was going to die, but the moment was also filled with love and humor.

When the nurses shared the special moment through a Facebook post, other Facebook users praised their actions in fulfilling Hansen’s last wish.

Users posted comments in support of the nurses, stating that the hospital provided hope, and some users even posted that they wished their own relatives had had such an experience.

Hansen passed away on April 28, but thanks to a special team of nurses, he got to live out his dying wish.

What do you think of the nurses’ actions in fulfilling Hansen’s wish?


7 Questions that Answer the Ultimate Opportunity of Leadership

The easiest thing leaders do is get things done. The hard part is the people.

Leaders are ineffective if all they do is get things done.

The true focus of leadership:

Leaders focus on people while getting things done.

The greatest opportunity of leadership is developing other leaders.

If you don’t get things done, you won’t be a leader very long. But ultimately leaders enable others to get things done. Now the question is, “What things?”

Leaders advance the welfare of others.

You earn the right to lead by advancing the welfare of others. But serving the greater good is only the first level of leadership. The hard part is next.

Leadership expands when the people you serve become leaders who enable others to serve.

The 3 Levels of Leadership:

Level 1: Advance the welfare of others.

Level 2: Influence others to advance the welfare of others.

Level 3: Influence others who influence others to advance the welfare of others.

How to serve those who serve others:

  1. Honor humility. Won’t honoring humility inspire pride? Not if you think of humility as behaviors and practices.
  2. Break isolation. Establish and strengthen connections.
  3. Clarify ‘good’. People must know what ‘good’ is, if they plan to advance it.
  4. Recognize service.
  5. Celebrate openness.
  6. Show enthusiasm, more than criticism, for others.
  7. Address tough issues with candor, empathy, and compassion.

7 Questions that develop leadership in others:

  1. If you were to exemplify humility today, what might you do?
  2. How might you help others establish and strengthen connections today?
  3. How might you advance the welfare of others today?
  4. Who might you recognize today?
  5. How might you be open to the suggestions and ideas of others today?
  6. How might you pass your enthusism on to others today?
  7. How will you acknowledge emotions and deal with tough issues at the same time?

How might leaders focus on people while getting things done at the same time?

How I Hire: My Guiding Principles


Experience and age are great gifts when it comes to effectively and successfully hiring and retaining great talent. Below are my guiding principles of hiring gleaned from 34 years of learnings — the four areas I focus candidates on and the questions I typically use as my filter in the first hour we have together.