How a Misalignment of Goals Leads to Bad Healthcare

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Ask a dozen reasonably well-informed individuals why their healthcare system is failing and you’ll get just as many answers. Incompetent management. Greedy doctors. Overuse of expensive services. Underuse of preventative care. Short-term planning. Inefficiency in the system. Healthcare industry lobbyists. A deficit of qualified healthcare workers. Russian disinformation campaigns.

While all of these answers may have merit (except maybe that last one), I’ve come to think healthcare systems fail because of something much more fundamental, something that repeats itself ad nauseum at both the macro and the micro level. You’ll find it from the governmental institutions that determine how health systems are financed and structured, all the way down to the individual hospitals and clinics that deliver care.

Bad healthcare can be directly linked to a misalignment of goals.

Bill Copeland is credited with saying:

The same can be said when goals do not align. If your team can’t agree on which goal to shoot at, you can run up and down the field until you’re blue in the face, but you cannot possibly win.

If I asked you: “As a doctor, what would you say the overarching goal of your work is?” How would you respond?

I’m guessing your answer would fall somewhere along the lines of “providing patients with good quality care”. (If, on the other hand, you answered “making money” then you are, in fact, one of the abovementioned greedy doctors and also foolish: there are much less stressful ways to turn a dime.)

Now what if I asked your hospital administrator, department head or human resources manager the same question? Would they name the same goal?

While it’s easy for healthcare institutions to glibly state their goal is to provide patient care, the real question is whether their actions support that goal, or whether they are designed to secure other aims. Aims such as saving money, running a profitable hospital, expanding the department, promoting a brand, or maintaining a ranking.

When our central goal as the immediate providers of care don’t align with those of the people in leadership at our institutions, it can become impossible to ensure the type of healthcare we know patients deserve.

To make my case, I’ve provided a real-world example from a hospital here in Berlin. And rather than offer my own opinions (though, as you might imagine, I have many), I thought I’d bring some actual expertise to the discussion by inviting my former professor, Peter Campbell, who teaches and consults on quality management of health systems, to analyse what went wrong and propose alternative solutions.

One Strike and You’re Out: The Downward Spiral of Mismanagement

At a small community hospital in Berlin, the nurses went on strike to demand better wages and staffing, among other things.

Peter Campbell (PC): For medical staff to go on strike it must be a serious issue. Medical staff are more philanthropic than most other types of workers (eg business, manufacturing, etc.), so to go on strike likely means the problems are deep. They may feel that patient care is being undermined by understaffing combined with overwork, low staff pay, and low staff morale. 

A way forward could be for management to really try to understand the staff concerns for their patients and for themselves and to work out with empathy how to meet their wishes.

Instead…

Hospital leadership were very unhappy with the nurses and unyielding to their demands. They did their best to undermine the strike and generate ill will and division among the nurses by saying how bad this was for the hospital, the patients, and the nurses who were willing to keep working under the given conditions.

PC: This highlights how the goal of managers is to save costs, and to do so by dominating the workers and creating a them-versus-us scenario. 

A way forward could be to view the staff as colleagues who do the actual hard work of daily caring, and who can only do this well with support from the managers. It would involve examining how we can work together to reach an agreement.

Instead…

Because no compromise could be found over the course of several weeks, hospital leadership mandated that the physicians in the Emergency Department must perform tasks that normally fell to the nurses- including triaging, cleaning the examining tables, performing ECGs, transporting patients to radiology for scans, measuring vital signs, etc. This was decided in order to keep the Emergency Department open at all costs.

The already overworked and understaffed physicians were angry at the nurses for being forced to take on additional tasks that were well below their qualification level. Others were angry at hospital leadership for letting it come this far.

PC: This approach to saving money is leading to a breakdown in working relationships, which are so necessary to good care. And, ironically, once good care is lost, costs start to increase. 

A way forward could be to heal the relationships through listening closely to everyone’s grievances and finding ways to resolve them through mutual agreement.

Instead…

The quality of patient care in the ED dropped. There was increasing dissatisfaction among both nurses and physicians (and, of course, the patients themselves), with several qualified and experienced staff members leaving their jobs for other hospitals. To fill these gaps- and due to a general lack of nurses- the hospital was forced to hire leasing nurses, which were significantly more expensive than staff nurses. The staff turnover also generated additional administrative costs. Moreover, the leasing nurses did not know the routines at the hospital and were therefore less efficient than the staff nurses.

More mistakes were made in patient care because there weren’t enough experienced staff nurses to explain certain hospital-specific procedures. Medication errors increased, emergencies were managed sub-optimally, and the burden on physicians intensified even more.

Over time, the costs were significantly higher than simply increasing the nurses’ salaries and/or hiring additional nurses would have been. The hospital eventually announced that it was facing possible bankruptcy and was forced to bring in external insolvency consultants.  

PC: The managers’ short-term goals of defeating the clinical staff may have won, but the cost was high. An analogy is found in the proverb “You might win the battle, but lose the war”. 

A way forward could be to understand this failure of the managers’ approach to save money and learn from this for the future. This might involve documenting the change in staffing costs and the cost of failed patient care, becoming aware of loss of reputation and potential loss from reduced income, and making new plans to deal with staff dissatisfaction in a different way next time.

Managers should be trained to work as colleagues with clinical staff, allocating a portion of each day to spending time with staff in all departments to understand their work and the issues they face.

In summary

What is the goal of a hospital?

All too often, different members of an organisation have different goals. Managers see their job as constraining costs, clinical leaders may see their job as keeping departments functioning, while lower-level health workers may see their jobs as doing their best for patients. But there should be only one goal for all: providing the best care possible to patients, while also aiming to do so as efficiently as possible.

This requires that all the organisational members work together for each other, but it needs the managers to make this happen. If managers have been taught that they have a different job (to care for money) and that they are separate from the clinical staff spatially and socially, then they quickly see the staff as a threat to their aims, rather than that their own management goals are a threat to patient care.

If these lessons are not learned from, then the next strike is just around the corner, staffing costs will keep on rising, and poor morale and lack of long-term staff will lead to poorer patient care, and a failing health system that ironically cares for money over patients, and in fact fails to care for either.

***

Peter Campbell, MD, MSc (www.petercampbell.info) is a Consultant in International Project Management (Public Health).

He has 25 years’ experience working to design, implement and evaluate health projects in low-middle income countries often on behalf of governments or development agencies.

He lectures Master and PhD level students at Heidelberg University on Quality Management and Consultancy Skills; and runs courses in Project Design and Health Financing at the Charité Medical University, Berlin.