Monthly Archives: September 2014

Eliminate the Hierarchy?

So a physician recently was working through the never-ending and ever-growing list of compliance training.  None of which has ever been shown to make health care better and all of which takes up precious time.  This compliance supports a self-serving industry.  Nothing more.

One of the compliance learning courses was intended to help providers develop a culture of health care safety.  The material in this course discussed toxic cultures and how they can lead to health care errors and patient harm.  So far so good.  Focus on culture.  Somehow the discussion then lead to a recommendation to eliminate the hierarchical structure in health care.  A dangerous statement.

Now, for the record when any member of HCR interacts with the health care system there will be a preference for the hierarchical health care system.  The hope is that a well-trained, well-educated physician is at the top of this hierarchy making all of the health care decisions.  He/she will work very closely with a team of providers (nurses, therapists, etc. but not managers or administrators) each of whom will have a job to perform.  Patient care will be discussed openly and each provider’s feedback and opinion is valued and important.  But there will be a hierarchy and the patient’s physician will ultimately make decisions and assume responsibility for those decisions.

The hierarchy is not the problem.  The hierarchy is a necessity.  There is a reason that it takes a long time and a lot of hard work to become a physician.  Any team needs to have a leader and that leader needs to be the person that is irreplaceable to the team.  In the health care system that person would be the physician.  The self-proclaimed and self-serving experts and advocates love to compare industries.  One “pundit” suggested that the hierarchy in health care should be eliminated making a comparison to the cockpit of an airplane.  The bizarre analogy was that if a pilot is going to fly a plane into the ground the existing hierarchy might prevent someone from intervening.  Seriously?  In this scenario the hierarchy is likely not the problem.  The problem is the pilot.  If a pilot is making potentially disastrous decisions and not receptive to suggestions from colleagues then he/she should simply not be flying.  This does not mean that the hierarchy is inherently bad.  For the record again,  when any member of HCR is on an airplane the expectation will be that a hierarchy is in place and that a well-trained and well-adjusted pilot is at the top of the hierarchy.

No, the hierarchy is not the problem.  A hierarchy is a necessity.  No hierarchy usually means anarchy.  It’s the culture within the hierarchy that is the problem.