How to deliver excellence in an organisation with stonewalled groups perennially at cold war?

Every hospital and NHS trust wants to perform well in achieving the key performance indicators; however, most of them failed to do so. My recent experience of handling the failures was eye-opening when I discovered the underlying cause to be a case of leadership complacency that was rooted in “learning to live with failures rather than risking a full-blown war”.

The hospital was falling behind in its theatre turnover and timely discharges. This resulted in red or black alerts (bed capacity constraints), cancellation of theatre lists and strained emergency care (such as patients waiting for hours for emergency hospital admission). Even though typical of any public sector hospital, this can affect any organisation in any sector. Organisations with top talents but missing performance due to stonewalled groups and the manager-employee divide plunge into mediocrity and catastrophic failures. It will be classified as a waste arising from unutilised talent.

The hospital had several physicians and surgeons who would carry out half the number of the procedures with delayed discharge compared to peers in the same hospital and in the region. Management tried to communicate directly and indirectly with this group of doctors however it only resulted in stonewalling and the development of impenetrable barriers over time. The hospital management put all its efforts into coaxing the consultants to perform the surgeries and procedures quickly thereby reducing the operating time and increasing the theatre turnover; however, rather than making any advances, all it did was create more roadblocks and barriers as the surgeons and physicians had a totally different take on it.

If the surgeons finished the case early, there was no incentive for them; the management would rather inundate them with more work, increasing the intensity of clinical activity. As per the doctors, this resulted in resentment and burnout but nonetheless, management never cared about this point. Many times, specialist doctors will carry out the treatment of sensitive and complex cases which would take more than usual time. However, the management’s lack of appreciation for the successful handling of these led to discouragement. Over the number of years, the highly talented group of surgeons and physicians got an informal conviction about the management line that all that matters is numbers and hitting the target rather than understanding the quality of care in complex cases.

As there are no metrics to study these, this was overtly demotivating for these top experts and their hard efforts. Chronic misunderstanding and cold war between the management and the set of doctors led to the development of complacency and resistance to the extent they were totally cut off from the rest of the hospital. Any attempt to bridge the gap would be seen with suspicion and met with firm resistance. Long-standing stonewalling has created such a vicious atmosphere that they don’t want to hear a word of criticism about their current mode of working. Any attempt at negotiation is seen as an act of war between the two rival groups and therefore best avoided.

I immediately realised from the story itself that top-quality professional hard work has been ignored and unappreciated. The doctors’ grievances are falling on deaf ears. The first thing I did was put my efforts to know them more, and approach them with words of affirmation. In my first meeting itself, the writing was on the wall that these are highly accomplished consultants who have worked hard for at least a decade with long hours and sleepless nights to get there. No money can buy them, but a sense of fulfilment, achievement, and words of affirmation can. Through empathetic and emotional communication, I made them feel heard. Providing them with undivided attention and quality time, was of utmost importance to connect with them at a personal level. A learning conversation that started I appreciated the concerns for their patient’s well-being and top-quality treatment.

I slowly got to understand that there is a WhatsApp group (Sir James Knight Group) of all these consultants who have internally established an identity that ‘we are not bootlickers of the management nuts who know nothing about patient care and only care only about numbers and targets.’ I was then introduced to one of the most influential members of the group (Dr James) who was a respected top consultant in his field of medicine.

I asked James how he was. He relayed that he struggles to articulate his emotions for this question; instead, he told me a story to describe his feelings. “An experienced knight who had conquered many wars and battles was driven out of his own castle; he was left to fight for survival against a castle full of friends turned into enemies. The knight is now exhausted and outnumbered, as the war seems to be endless. Haunted by the memories, smell the of death in the air, and blood on his skin, he forged an alliance with a few loyalists and finally found solace in a Sir James Knight WhatsApp Group…”

The past experience of humiliation, harsh treatment, and undermining is common to all the members of this group. It was the binding force and created a tribal effect in the group that pitted the “we vs them” identity in them. One notable point of this group was that ‘homo emoticus’ had somehow superseded the ‘homo economicus’. I had to ensure that I don’t enter into any identity conversation with them.

My pair of sympathetic ears helped them to introspect where things might have gone wrong. Why is their perception of high standards of care often met with resentment? Why was their expert care not aligning with the vision of the trust? In a reassuring environment with positive vibes, unspoken things started coming out from under the carpet, such as poor peer support that led to a lack of prioritisation and indecisiveness in complex case handling. Given the vicious environment in the trust, they wanted to play safe rather than bring any cost-efficiency or turnover to their operations. For example, when there is a resource-efficient way vs the gold standard without much difference in the outcome, they would prefer the gold standard even if it means a waste of resources and time.

Playing safe with medic-legal threats from patients and peers, this isolated group of physicians and surgeons were totally disconnected from the management and the rest of the hospital. The disconnection was visible in any departmental or organisational meetings; however, the management did not have any clue as to how to penetrate the narrative and perception bubble which are mainly based on professional standards and regulatory requirements. For example, when the doctor quotes certain professional guidelines and regulatory requirements to meet the gold standard for certain procedures and operations, the management had little to say or counter these.

The discussion with the management and the consultant groups helped me to realise that patient care takes place at the intersection of the conference of the regulatory requirement, professional standard requirements, patient requirements and the business requirement of the trust.

When personal coaching in a non-threatening non-judgemental environment allowed the grievances to be aired and allowed the consultants to become more open-minded and considerate to the opposing views rather than jumping the guns. Slowly, it helped them to come out of the hard-shell stereotypes and helped them onboard with the trust’s vision and goals. By asking the right questions about their assumptions and interpretations of professional standards and regulatory requirements, the discussion flowed in the areas considered untouchable before. It helped these professionals to introspect and come out with alternative acceptable solutions. This led to a reduction of the operating time, increased turnover and helped you to reduce the variation in the care standards provided by thephysicians and surgeons.

What should you do as a leader when you must endure and navigate through the dirty politics of the organisation to deliver high standards of care? When intense group politics and rivalry engulfs the department, and affect the standard of your patient care and the key performance indicators, what should you do? Should you dream of a resounding victory bringing clinical governance to the fore for a quick win when you have a strong opposition at war?

Here are the following solutions

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