Ripples of a Healthy Hierarchy!

In order to create and sustain a healthy culture and achieve critical outcomes…

• Patient safety
• Patient experience
• Workforce health & wellbeing
• Cost-effectiveness

…the hierarchy must be healthy!

In a healthy hierarchy, staff must have the right skills, education, and experience to direct and carry out clinical-and care-related tasks. Clear lines of communication, roles and responsibility are all important. We can think of such things in terms of the structure.

We should also consider the hierarchy in terms of process! This refers to how clinical and care decision-making is informed and carried out by the people involved. It is the more fluid part of a hierarchy which involves communication, relationships, and culture. In a healthcare hierarchy, the fluidity within the structure is evidenced in part by staff’s abilities to challenge authority and authority’s abilities to invite and consider them.

This is important for ensuring all relevant concerns, questions, ideas and information are available for decisions at any given moment. This process requires competencies associated with communication and underlying emotional intelligence and a culture which supports their practice. When things go wrong there is often a process-related cause!

In order to appreciate this idea, we can examine three process-related traits that are prevalent in a healthy hierarchy.

3 Process-related Traits of a Healthy Hierarchy

#1: Staff are skilled in giving and receiving constructive feedback & supported by the culture.
In a thriving hierarchy, feedback is fuel for teaching and learning. Staff at all levels are in a dynamic dance of exchanging experience, knowledge and skills. Mistakes or problems are opportunities for individuals and teams to grow personally and professionally and improve outcomes.

Leaders make it a priority to ensure effective feedback training is provided and the expectation for practice is clear to everyone.

Guidelines for giving and receiving constructive feedback are fairly straightforward, but without a culture where people feel safe to speak up and willing to listen, the practice is hard if not impossible to maintain. Pervasive bullying or blaming can shut down even the most emotionally intelligent and assertive professionals.

From a communication standpoint, it is worth noting that giving constructive feedback is an assertiveness skill and receiving it is a listening skill. Both require emotional intelligence, such as self-awareness, confidence, empathy, and perspective-taking!

#2: Everyone has the capacity to lead and follow

In a thriving hierarchy, everyone on any team or in any position will have the capacity to lead and to follow. Like feedback, both involve listening and speaking up skills and a supportive culture. In such a culture, everyone feels respected, safe to and accountable for speaking up.

Historically, the healthcare hierarchy has been a top-down structure that predominated military and medical models of the 20th century. Here, doctors give orders to nurses and other professionals, nurses and others follow them and they give orders to paraprofessionals. A process that generally speaking makes sense from a clinical standpoint as those with more knowledge, skills, and experience direct the decision-making process.

It isn’t foolproof though because the people at the top of the hierarchy are not always the ones with vital decision-making input to share. When there are toxic issues involving status, power, or ego among people or within the culture this more collaborative element of communication is hindered. And sometimes with catastrophic results!

Some of the most sophisticated physician and nurse leaders I have seen in action are able to direct care and build a culture of trust where everyone is respected. With grace and clarity such leaders move from authoritative to collaborative leaderships styles and back in real time. It is also impressive to see courageous support staff such as nurse assistants or housekeepers jump into a leadership role with vital input at any given moment. Such fluctuations of leading and following are incredible to watch, enriching for everyone and so much safer in terms of care.  The more we cultivate these skills in everyone, the better our outcomes will be!

#3: Respect, trust, and dignity are in the air

Respect, trust and dignity, are hard to measure and difficult to teach. Yet we all know what they look, feel and sound like. When these ideals are present, people are busy, yet there is a sense of overall camaraderie and interdependence. Leadership and teamwork are amazing and teaching and learning are ongoing processes. Patients see how people treat each other and are more likely to feel (and be) cared for by the entire team! Work is more rewarding and mistakes and burnout; less likely.

Alternatively, disrespect, distrust, or indignity are phenomena that plague toxic cultures. They breed the bullying or blaming, which many of us are familiar with. And all of our outcomes suffer.

How Medical Improv Helps

As you read these traits, you might be wondering how on earth can we cultivate such behaviors?  How can individuals develop abilities for showing ownership, apologizing, speaking up, leading, following, appreciating other perspectives, forgiving one’s self and others, and similar behavior. They represent such challenging social and emotional development and they are practices that probably won’t be sustainable for long in a culture of bullying and/or blaming. 

Unless…unless there is an influx of individuals who have these competencies or an intervention that promotes them collectively.  In which case, shifting the hierarchy and culture to one where respectful interactions are supported becomes possible. Then there is a ripple effect. A very positive one. 

Medical Improv is an effective intervention because experiential activities when facilitated properly,  become tools that build the ‘soft’ skills that promote positive relationships and effective communication. Competencies which contribute to healthy teamwork, hierarchy and culture.  All of which will in turn support practicing the skills.  Medical Improv tools are based on a “YES AND” philosophy where MANY experiential activities can be used to help accomplish all of these objectives. 

I’ve been researching, teaching, and writing about communication-related skills and healthcare outcomes for over 20 years and integrating experiential activities from the world of improv for about 15 of them. Without a doubt, it is the most effective and engaging modality I know of!

If you’d like to learn more about how Medical Improv works, please join me on April 19th, 12:00 – 1:30 pm ET,  for  an interactive and experiential introductory session! 

“YES AND” 101 for Healthcare & Mental Health Care Visionaries
(It’s free and online!)

Coming Soon: “The Medical Improv Toolkit!”

Also, I’m excited to announce that my next book, The Medical Improv Toolkit: 10 Simple Activities to Promote Safe Care, Healthy Workplaces, & Rewarding Careers is in the final stages of production! 

Written with contributing author and developmental editor, Ellen Schnur, DTM, CP this toolkit has everything leaders and managers need to start facilitating simple and quick activities with their teams and create a positive ripple effect throughout their organization!

Medical School Professor, Physician and Improvisor, Dr. Michael Smith, MD of Healthcare Improv has agreed to review a draft soon and hopefully write the Foreword while national/international Leader, Educator, Author, and Clinician in Integrative Health and Nurse Coaching, Mary Elaine Southard, DNP, RN will do the same re: the Afterword. I am excited because I have so much respect for these professionals and know they understand the mission of this book!

To receive pre-order notices or explore a variety of articles, interviews, and other related resources check out: Medical Improv Events & Resources!

As always, reach out anytime with feedback, questions etc! Beth@bethboynton.com