No need for managers in healthcare

2 November 2020

Arnout Orelio

Many articles or LinkedIn post about problems in healthcare, for example rising costs or underpaid nurses, provoke reactions about (too many, “expensive”) managers. “Just remove two layers of management”, someone wrote, for example. “Sounds very ‘lean’ to me”, I hear people shouting in the back of my mind 😉

Apparently there are large groups of people who don’t see the point of having managers. Removing managers from healthcare therefore seems like a good idea for many people. An understandable idea. If you think that something or someone is of no value, you take it away. So also the management?!

But, … If you remove the managers, then what is intended still does not happen!

What is actually the meaning of “management”, in healthcare? The purpose of management is – in my opinion – to make sure that the right thing happens for patients: safely and with compassion, the right care, at the right time, at the right location, without waste or struggle.

This is an ideal that, if you pursue it, continuously asks for problem solving, process improvement and the development and growth of medical professionals. If this is not what is happening in your hospital or healthcare facility, there is no point in replacing or even removing the managers. It is not the individual managers, but your management system that is failing. The “wrong” behavior of managers is a symptom of a “bad” system.

“If managers do not do what is necessary, then change your management system (= the way of managing), not the managers!”

Healthcare, without managers

There is a lot of interest in self-management in healthcare and in the idea that healthcare can do without managers. Organizations such as Buurtzorg, a home-care organization from The Netherlands, have shown that you can successfully provide care “without managers” by having employees in teams organize and manage themselves. It deliberately says “without managers”, because self-management does not mean that you can do without management. You still want, with or without managers, that everyone does the right things for patients, in a financially healthy way.

What is required to pull this off?

If you want healthcare professionals to manage their own processes, this requires a matching management system. This management system must ensure that team members:

  • Know what the ultimate goal, True North, is, so that everyone in the team and across teams works in the same direction.
  • Know what the main challenges of the organization are to stay on course and what contributions are needed from them and their team
  • Know what the work is: what should we do, when, how and for whom?
  • Know at the first possible moment that there is a problem or abnormality.
  • Do not forward the problem to their colleagues and/or patients.
  • Have the time and opportunity to address a problem.
  • Have the skills to analyze and solve the problem.
  • Have the necessary help immediately available.
  • Can get back to continue their work as soon as possible.
  • Learn from it all
  • The leadership to continuously improve.

That’s quite a list! And not just a list, but the characteristics of the management system that is needed. In other words, all these elements only work if they are all present and connected to each other. The interconnectedness determines the results of your system.

A Daily Management System for Teams? 1

How can you, with your team, manage your care processes? You need a management system at the level of your team.  If you read the above criteria for such a system then I understand, if you find it all very comprehensive and overwhelming. What can you do as a team to develop your own working management system today?

Only through intensive collaboration between all disciplines in the care process can patients receive the right care at the right time. To ensure that everyone works in the right direction, you need to have a clear understanding of the purpose of the process and the collaboration. In other words: you want to have a clear idea of what the added value is for your patients. You make this added value visible, so that you can see at a glance whether the right things are happening and/or whether there are deviations. For example, you could start by checking whether the care has been delivered on time, patients are discharged at the right time, all necessary actions have been performed and/ how the patients have experienced the care.

Discuss how your team has performed on a daily basis, so you can compliment people and adjust if things have gone wrong. But most of all, to be able to learn together. Adjustments are always made in the direction of your ideal, True North: added value (the right care) for each patient, at minimum effort and cost.

By thinking about how things are going every day – or even more so with every patient – you avoid losing (read: forgetting) the facts about your achievements and problems. In this way, people also account for their own performance and contribution to the team in a safe and process-oriented way.

A well-known example of such a daily accountability is a huddle. A huddle is a short, stand-up meeting, often at a whiteboard on which the performances, actions and agreements are made visible (see figure for a possible design of such a “daily improvement board”). The team discusses the achievements and problems with the aim to involve all team members, to get them thinking, to learn and to come to improvement actions.

One of the tasks of your system is to detect, analyze, solve and prevent any deviation from your (healthcare) standards (the desired situation) in the future. To do this, install a possibility on the work floor to directly call for help, a so-called andon2. Think, for example, of a traffic light, so that your colleagues and/or your team leader know that something is going on and how urgent it is, so that they can come to help as quickly as necessary. Problems that the team cannot solve,  you take to the next level, if necessary all the way up to the CEO.

Who is responsible for the management system?

Who is going to take care of this? That all elements of your management system for self-management are present in all your teams and that they are connected to each other. This is a task of the management (within an organization with multiple teams). Also at Buurtzorg. What makes that they have succeeded and many others haven’t? Because Buurtzorg is self-managing from the start; including the founders. So they didn’t have to change “anything”. Their most important task is to monitor and nurture the culture and the system within which self-management can take place.

Existing organizations, with a culture in which managers are the decision makers, find it very difficult to evolve towards self-management, because they, the leaders, forget that this requires a culture and system change. They are often inclined – under the guise of “self-management” – to delegate responsibility for implementation. Beware of this! Before you know it, you have appointed an (extra) “manager”.

A culture change starts with changing your own mindset and your own behavior, as a leader. I see in many organizations that this step is skipped. My most important advice if you are considering self-management:

Self-development and not self-management, is the first step!

[1] A. Orelio, Lean Thinking in Healthcare, 2023, Chapter 8.

[2] Andon is a system, developed at Toyota, that is intended to give employees the opportunity to call for help with a quality or process problem, by means of a visual signal. Everyone at Toyota is authorized (actually obliged) to use the andon and thus slow down or stop the production line!


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