Hospital Work Design and How To Improve It

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In the past weeks, I’ve written about the influence toxic leadership (The Subtle Signs of a Toxic Work Culture- Part One) and toxic social norms (The Subtle Signs of a Toxic Work Culture- Part Two) have on work culture and how this plays out in the hospital. This week I’m wrapping up the three-part series by examining the role of work design in toxic work culture and what it takes to improve work design in the hospital.

While the data shows that toxic leadership is the biggest contributor to toxic work cultures, it’s important to note that problematic work design contributes to toxic social norms, meaning that it’s impact on toxic work culture is amplified. In How To Fix a Toxic Work Culture, Donald and Charles Sull describe the connection between work design issues and toxic social norms as follows:

‘Stressful jobs are a breeding ground for toxic behavior. Regulating emotions and resisting negative impulses requires energy. Mental stress depletes limited stores of energy, making it harder for people to control their negative impulses.’

How To Fix a Toxic Work Culture, by Donald Sull and Charles Sull

It’s fairly easy to imagine what toxic leadership and toxic social norms look like. The individual elements of work design are not as readily apparent. Charles and Donald Sull break down work design into role conflict, role ambiguity, empowerment, and workload to demonstrate how much each of these areas contributed to toxic work cultures in their research. But how- if at all- do these categories translate to the hospital world?

It’s no secret that work design in hospitals is riddled with problems. Universally cited issues include too much time spent on documentation, too many patients to care for in too little time, too much red tape, and the burden of long days, night shifts, 24 hour shifts and weekend work.

Physicians are, overall, a resilient bunch, willing to take one for the team in the name of patient care. But the generation of doctors who were prepared to put up with the vagaries of an intrinsically flawed system is being replaced by one that increasingly insists its needs not be sacrificed at the altar of willful disregard. More and more physicians are voting with their feet, pushing back against working conditions that are simply incompatible with a full existence.

According to a statement by the German physician’s union Marburger Bund, one in four hospital physicians in Germany is contemplating a career change. In the US, recent surveys show physicians leaving hospital employment in unprecedented numbers. These statistics paint a clear picture, one that demonstrates an overdue need to redesign what hospital work looks like- or face a dangerous scarcity in access to hospital care.

The structural changes needed to overhaul our faulty healthcare systems won’t be achieved overnight (or ever, unless we start to take meaningful action). The good news is there are work design issues amplifying the negative consequences of these big tickets items that can be fixed now. But just as with toxic leadership and toxic social norms, fixing them first requires we give up the myth that hospitals must inevitably operate this way and begin to question why approaches that are readily available in other industries remain out of reach for the hospital world.

Onboarding

For each beginning bears a special magic that nurtures living and bestows protection.

Steps, by Herman Hesse

If there is one way to identity flawed work design from day one, it’s by taking a close look at the onboarding process in the hospital.

What exactly is onboarding? It’s not just about completing mandated online trainings, filling out all the forms HR throws at you, getting your ID, and learning to use the software (although those are a start- I’ve been in hospital positions where even those steps weren’t clear.) It’s the process of introducing new employees to the inner workings of an organization, everything from culture and values, to internal structures, to policies and procedures. It involves giving new hires the tools and resources they need to transition effectively into their role and integrate seamlessly into their new team.

If you’re thinking to yourself: ‘Sure, in the corporate world, but this is a hospital’, then you have successfully demonstrated the problem. (And if you’re in the corporate world and asking yourself why we’re even talking about something as basic as onboarding, now you begin to understand the problem.)

It’s easy to assume that in hospitals culture and values are pretty universal and need no elaboration. But while we hopefully all share a dedication to the best possible patient care, other aspects will differ between hospitals. Some hospitals will have an emphasis on innovation, others may favor integrative care, still others may prize advocacy and community outreach. And naturally, the individual policies and procedures along with the necessary tools and resources to implement them will diverge significantly from one hospital to the next.  

In the United States, where residency is highly structured, the onboarding process for interns is generally well-organized. In Germany, on the other hand, residents find themselves tumbling straight out of medical school and onto wards, emergency departments or delivery rooms with little to no formal initiation. And even in the US, once the residency and fellowship training wheels come off and doctors enter the next phase of gainful employment, onboarding runs the gamut from regimented to nonexistent.

When hospitals fail to establish a formal onboarding process, they expose a lack of cohesive structure, strategy, and commitment to creating successful teams united by a common mission. First, it drains one of the most valuable resources in a hospital: time. A lack of clearly structured initiation hinders physicians’ ability to work efficiently from the start, forcing them to waste time figuring out the ropes or humbly ask whoever might avail themselves- at the cost of their own precious time.

More importantly, it squanders a unique opportunity for oncoming doctors to feel welcomed into an existing team with a strong set of values and clearly demonstrated social norms, which is a huge downstream contributor to identifying with the organization and its mission. This identification is what generates healthy loyalty toward a department, the kind that reduces turnover and helps insulate against internal resentment and frustration.

Creating functional teams starts with an intentional process of integration, one in which expectations are clearly set, roles clearly defined, and support readily given.

Workspaces

I’ve never worked in a hospital that didn’t neglect the basic physical needs of the physicians working in it. If you’re as sleep deprived as I am, you may immediately think of nights spent roaming the hospital halls, zombie-like, yearning for the moment you can finally go lie down in the broom closet that doubles as an on call room . (Or you may be thinking about hospital cafeteria food, also a fair point). But it actually starts with something as simple as workspaces.

When was the last time you saw a hospital administrator crammed behind a desk side by side with two other colleagues, sharing a screen because there aren’t enough computers to go around? And yet, in so many hospitals, this is exactly how doctors are expected to work. I’ve seen shiny university departments with fancy names in which six people shared one desk and physicians had to take turns using a computer. I’ve sat in windowless work rooms with up to twenty medical students, residents, fellows and attendings trying to teach, round on patients, discuss complex management plans and work on patient notes while in the background phones rang and pagers went of incessantly.  

Physicians are expected to process highly complex information, to take in huge amounts of data and turn it into a diagnosis, to craft the best possible treatment plan when the stakes are another human being’s ongoing existence. And yet, so often, they aren’t afforded the absolute minimum of space and quiet to do the focused thinking this requires.

This disregard for the fundamental infrastructure needed to perform their work demonstrates a pervasive attitude that physicians must be so adaptable as to forfeit all needs. And yes, we are adaptable, or we wouldn’t be in this role. But it’s hard to imagine another industry where the stakes are so high and the investment in a basic working setup so neglected.

Digital Technology

Speaking of infrastructure, a word on digitalization. Excessive workload, disproportionate amounts of time spent on documentation, medical errors- these are key issues in the hospital environment that can at least be mitigated by well-designed digital systems.

In Germany, the land of high-tech engineering, hospitals are still using paper-based patient charts and records. (Yes, you read that correctly. On your personal computer or the hand-held device every one of us carries on our person. Because it’s the year 2023.) And even where digital ‘solutions’ (I use this word very loosely) are being implemented, the execution often borders on the absurd.

I will never forget taking call at- let’s just say a renowned European university hospital, to refrain from naming any names- and being tasked with caring for some of the most complex patients in the country on half a dozen subspecialty units as well as supervising the Emergency Department and all new admissions. During my shift, admission orders were first handwritten on a paper chart by the ED resident. I then had to type those orders into a digital data entry system. After which the nurses handwrote those same orders into another physical paper chart. I kid you not.

It goes without saying that a lack of investment in functional digital technology is a huge drain on physicians’ time, time that is then siphoned away from immediate patient care and medical management. Ultimately, this ends up costing the healthcare system so much more than the expense of investing in appropriate technologies. It is also an enormous driver of physician dissatisfaction in the hospital. We are currently seeing an explosion of AI applications, which provides unbelievable new opportunities to streamline and improve patient care while allowing physicians to focus on the aspects of our jobs that genuinely require our particular skillset. In this era of unparalleled digital innovation, there is absolutely no excuse for poorly designed or absent electronic medical record systems in hospitals.

Schedules

Somewhere along the way, it was decided that physicians can reasonably be expected to work twice as many hours as the average work week. Why? Because it’s simply cheaper that way. In the past, doctors have too often embraced this notion wholeheartedly in the belief that it somehow makes us better at our profession. I think it’s fair to question that notion just as we would question the idea that pilots will fly better if they haven’t slept in 48 hours because of all the extra experience they’ve gained during that time.

The long hours are exacerbated by steadily increasing workloads that have fewer physicians seeing more patients due to a relentless push for hospitals to cut costs. This comes at a time when the complexity of patient care has increased significantly in the wake of ever-expanding options for diagnosis and treatment of chronic diseases.

A notable side effect of this excessive workload is that it effectively prevents us from reflecting, questioning the status quo, and pushing to redesign the existing system. When you’re drowning, you’re rarely in a position to remodel the boat.

The detrimental effects of extreme workload are difficult to mitigate. While Sull and Sull found a positive impact of empowerment on other toxic work design, they also point out its limits:

Providing employees more control over their work can mitigate the negative impact of unclear or conflicting roles and responsibilities. Leaders should not, however, view this as a license to pile ever more tasks on their employees, because empowerment cannot offset extreme levels of work.

How To Fix a Toxic Work Culture, by Donald Sull and Charles Sull

So what can be done in the short term to alleviate the impact of ubiquitously high workloads? One answer lies in transparent and predictable schedules and fair compensation of additional work.

Unpredictable schedules add a huge burden to already overworked physicians trying to balance their personal lives with the demands of the job. When the islands of rest and regeneration or family time between long work weeks are frequently whittled away by short notice requests to take on extra shifts, it inevitably drives burnout.

Doctors are often pushed to take on this extra work willingly, as a sort of moral obligation toward our patients. An insistence on needs of our own is quickly dismissed as selfish- even from within our own ranks. It’s another excellent example of the passion tax doctors pay: the expectation that working in a profession we consider a calling means we should be willing to accept whatever conditions are thrown our way.

This barrage of short notice requests to take on more work is framed in a way that suggests unforeseeable events or unexpected emergencies as the cause. In actual fact, they are the predictable consequence of a planned deficit in personnel. Why? Again, because it’s cheaper that way. True unforeseeable staffing shortages can be met with models like those that have been in place in some European countries for years and are now being increasingly negotiated in Germany. Short notice shifts are compensated by a tiered increase in pay; the shorter the notice, the higher the compensation. Models such as these create incentives for physicians to take on extra shifts while decreasing incentives for hospitals to cut costs by paying fewer physicians to do the same amount of work.

Finding Our Voice

There are several possible responses to issues in work design and toxic work culture in general.

Employees can respond to a toxic workforce through exit (disengaging from their work or quitting the organization), voice (lodging complaints with management or posting negative reviews of their employer), or loyalty (sticking with the employer despite the toxicity).

How To Fix a Toxic Work Culture, by Donald Sull and Charles Sull

For physicians, part of the issue is that we have not learned to use our voices effectively. But a change is coming. I see it in my younger colleagues. I see it in the strikes that doctors are participating in across Europe. I see it in the push for mental health awareness and discussions of wellbeing at work. There is an opportunity here. A chance to take everything we know about toxic work culture and reverse engineer it into healthy, thriving work environments. One in which efficiency and kindness, a drive for excellence and a concern for needs, daunting challenges and determined support can all coexist.