Thursday, February 17, 2011

The Bus or the Rope?

How many times have you heard leaders talk about “getting the right people on the bus”?

I find that analogy in health care to be difficult. It just doesn’t resonate with my experiences or my sense of how we should be thinking of our work on behalf of patients. First, let me outline why the “bus” and its occupants makes me uncomfortable. Then I’ll outline a model that makes more sense to me.

Ask a group of physicians or executives where they’ll be sitting on that bus if they’re the leader. The immediate and most common response is, “In the driver’s seat, of course! I know where I want to go and how to get there. I want people on the bus who support my direction.”

A few want to sit in the back and monitor what’s happening as the bus barrels down the freeway. Some are comfortable with rotating drivers.

Are riders on your bus comfortable pointing out problematic strategic, operational, or patient safety-related decisions? What do you do if your riders disagree with you? Usual responses: “They’re asked to get off the bus” or “They’re thrown under the bus!”

Ask about where the patient rides on the bus. That question gets some very interesting responses: “Somewhere behind the driver”; “In the driver’s seat”; “In the baggage compartment.” That last response gets a lot of laughter, and heads nodding in agreement.

Now imagine a different image. Imagine you, your team of health care professionals, and a patient are on a rope, climbing a mountain in the Rockies, Andes, or Himalayas. You are all linked together on that rope, all with the same goal. In health care, it might be evidence-based medical care, highly reliable and safe care with optimal outcomes, or patient centered care. It’s risky work. There might be many ways to get to your collective goals, but it will require input from everyone.

It might also require vigorous disagreement from time to time about the safest and best way to proceed. If you’re the leader of the team, and know how you want to achieve your goal and how fast you want to get there, are you comfortable with agreement, or perceived agreement? No one speaks up. Do you assume everyone agrees? Do you want to encourage disagreement before starting up that dangerous part of the journey?

As you proceed up that mountain, you’re about to step in a crevasse. We’re all prone to mistakes as human beings. How do you want the team member behind you on that rope to respond? I want to hear, “STOP – that’s not safe!” Or feel the sudden tightening of the rope as an ice axe is plunged into the snow. We’re all in this together – each one of us concerned about one another’s personal and professional safety – regardless of our status in the hierarchy of the team. What happens to one of us is likely to happen to everyone else on that rope.

Finally, imagine a situation where the patient is the only person on the rope who isn’t ready, or in shape, for the push to the top. Not strong enough. Circumstances don’t seem auspicious or comfortable. Do we have the courage, compassion, and situational awareness to listen? Do we decide to wait until another day or moment, or do we drag the patient up to the top because the health care team believes it’s the right thing to do?

Put me on a rope with people who aren’t shy about voicing their concerns for patients, and for safety. People who can be counted on to do what’s right, for the right reasons. I don’t mind if those people are a little rough around the edges. If everyone realizes that the most important individual on that team is the patient, we’ve got a great team! Come to think of it, maybe that patient is the true leader of the team.