An Open Culture vs. the Top-Down, Hierarchical, Command & Control Management Style

Coming out of residency in 1996, I was very fortunate to join a physician-owned, multi-specialty group that had a very healthy, open culture. We had a phenomenal, visionary administrator who taught us the business acumen of healthcare and was responsive to our needs and concerns.  Decisions were made together as a cohesive group of physicians who greatly trusted and respected one another.  Over the next 16 years, I slowly watched other previously thriving, privately owned healthcare facilities be gobbled up by big corporate business.  Many were replaced with Top-Down, Hierarchical, Command & Control management models, headed by MBAs and finance people with little if any healthcare background. 

As I tried to make sense of this shift, I began fervently studying physician leadership, starting in 2008. We decided to move west in 2013, and I experienced practicing medicine within a bureaucracy, in not just one, but two different organizations. Needless to say, this was NOT comfortable as the differences are absolutely striking.  

I continued my formal leadership training to stay abreast of this paradigm shift, including becoming a Certified Physician Executive through the American Association for Physician Leadership.  Many great thought leaders have helped me shape my leadership philosophy on this journey. Jim Collins and many others agree and explain, hierarchy creates bureaucracy, which impairs team functioning and kills the entrepreneurial spirit.  

The purpose of a hierarchy is to:

• control people you don’t trust,
• to compensate for incompetence and lack of discipline,
• to manage the small percentage of wrong people on the bus, which drives away the right people from the bus. This in turn increases the percentage of wrong people, which increases the need for more bureaucracy => Flywheel of Doom, a Death Spiral, and a Cancer of Mediocrity.

Bureaucracy is a Potential Crusher

“The old boss-to-employee, command-and-control leadership (autocratic style) ‘works’ when it comes to building process-efficiency systems, engineering large buildings and creating infrastructure (start up organizations).  But the top-down leadership techniques of the past have not adapted to a workplace that now demands coaching and collaboration to thrive.” This is one of the least effective leadership styles as it disempowers employees and can lead to high turnover, low morale, and decreased productivity. [“It’s the Manager,” Jim Clifton and Jim Harter, Gallup Press. 2019.]
 

By now, most of us have experienced the headaches associated with an autocratic leadership style, including loss of autonomy and influence within our own healthcare industry. People in this type of environment often do not feel appreciated, valued, or recognized for their contributions.  The primary stakeholders - physicians, lose influence while watching more and more positions get filled based on criteria other than what we would consider appropriate merit.  This creates an unhealthy, competitive, and punitive culture where people must first find a way to tolerate it, and eventually rather than fight the system, they join forces with it.  People trapped in a bureaucracy turn in on themselves, have turf battles, worry, argue, and scheme against one another to claim, keep, or climb positions of power on the corporate ladder. They become self-centered and forget about the people that they work with and those whom they are there to serve.

The Top-Down, Hierarchical, Command & Control system has become commonplace in healthcare. The CEO typically communicates the vision to the upper echelon of directors and chiefs.  They hammer out the strategy and tactics and deploy the managers to cascade the information down the ranks for the front-line employees to execute.  These are concepts that employees, including physicians did not help create, therefore are less likely to adopt without a significant amount of resistance to the change. Managers claim it’s faster and more efficient to just tell team members what to do and make sure they deliver, or they will get “written up.” 

Talking Points: 

• The employee mindset with a carrot-and-stick leadership style does not motivate, cultivate trust, respect, or freedom to buy in.  It is a forced transaction that more often creates resistance.
• It makes employees feel like children being forced to comply with stringent rules, or risk being punished.
• It discourages open communication and creates a culture of fear because input and feedback are not welcome.
• It undermines people’s self-worth and suppresses creativity, innovation, and maximum potential.
• This environment creates entangled agendas, negative emotions, and power dynamics; nobody does their best work here.

Another problem that this Top-Down, Hierarchical, Command & Control system has created in healthcare is an unrealistic workload.  When outside agencies create policies that are not physician centric, there is often a mismatch between unreasonable demands/expectations and the capacity to realistically meet them!  Then if incompetent leaders resort to Accusing, Blaming, Criticizing, and Demoralizing staff (ABCD leadership) for not being able to meet these demands, moral injury occurs, leading to higher burnout and turnover rates!

Most healthcare workers agree that the moral injury occuring within the Top-Down, Hierarchical, Command & Control Management Model is not sustainable and large sweeping change is necessary. 

Christina Maslach is coined with the standard definition of burnout which we all recognize, but also includes, “Physician burnout can take you on a relentless downward spiral that has been described as, an erosion of the soul caused by a deterioration of one’s values, dignity, spirit, and will.”  It should be of no surprise that the burnout rates have skyrocketed to over 60%.  

The causes of burnout are many and are unique for each individual, including the specific system-related circumstances at play within the organization!  It takes duo strategies to manage the individual and system issues contributing to this complex dilemma.  There is no quick fix and contrary to popular belief, it is NOT typically due to some individual personality flaw or weakness!  

The starting point for any team is, to be honest about the demands/expectations that you face and respectfully discuss the reality of what you can safely deliver.  Everyone understands that if all your hospital beds (or appointment slots) are FULL, you must DIVERT!  This is also true for the individual clinician - no matter the title, or role - there is only so much any one individual can do - respect human limitations and respond appropriately!!!

Rather than making erroneous or accusatory assumptions, leaders must be supportive, get involved and participate in these crucial conversations with the clinical teams during huddles. YES, the best teams have administrators who round on their teams and are present for a percentage of their huddles – to understand what the issues are, to problem-solve together, and make appropriate, tangible decisions to support the team! 

For many organizations, that means accepting that the system doesn't have enough capacity, and being real about the vulnerabilities that exist as a result.  Then, the team must create a disciplined, respectful approach to assure quality and safety and to share the load in the most efficient ways possible. The leadership must be present, onboard, supportive, and prepared to make wise hiring decisions, as well as remove any/all roadblocks for the team to be successful.

Performance improves when the leader gets better - Re-cultivate an Open Culture:

• The leader must BELIEVE that employees are fundamentally GOOD; thus treated as trusted partners/owners, instead of like machines. “Machines” are inanimate objects, expected to just do the job without askinq questions.  Things like supplies, equipment, and financial statements are to be managed. People are to be led with a respected voice and input.
• If your organization says ‘our people are our greatest asset,’ you must ACT like it and default to an open culture. Openness demonstrates that you believe your employees are trustworthy, have value, and good judgment.  Giving them a voice within the context of WHY and WHAT is happening will enable them to collaborate, learn, do their jobs more effectively, and contribute to the HOW in ways that top-down management cannot.
• In an open culture, the responsibility for creating a compelling Vision is still with the Leader (See the image). The vision must then be communicated effectively within a clear Leadership Framework – unleashing the potential of a well trained and responsive staff. The leader must then step aside and his role becomes support for Implementation. (The roles flip - see the image).
• Implementation - the STAFF are now at the top - responsible for responding to patients' needs and are the ones suggesting to leadership what needs to change for continuous quality improvement and safety. 
  • The entire organization is entrusted to be responsive to the Vision, and now implement measures within the Leadership Framework to soar like eagles with an ownership mentality and achieve the stated goals.
  • The Leaders SERVE, support, and respond to employee needs - training, developing, and empowering them to efficiently and effectively accomplish the established goals.
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• Bureaucracy Busters = Everything is up for question and debate, from anyone. Every question is fair game and deserves to be answered. Employees are encouraged to submit questions directly or online, so all can see them, discuss and weigh in on them => synergistic GROUP decisions.
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• Great leaders empower employees with decision-making authority - show them the Leadership Framework and set their creativity free.
  • They provide safe learning and leadership opportunities outside what is necessary to do their immediate job descriptions.
  • They increase reliance on teamwork, rather than the top-down hierarchical decision-making, giving teams more autonomy, and allowing them to problem-solve for the things that matter most to them.
  • They develop a culture of high performance so that teams thrive and consistently reach the goals.
  • THAT produces a great culture that most of us would be proud to be a part of!  I not only greatly miss that, but will forever advocate for the return to this type of an open culture!