Published: 13/05/2004, Volume II4, No. 5905 Page 18

Irwin Rubin is co-author of the first UK edition of a landmark book on organisational change in US healthcare organisations. He talks to Nick Edwards

My pulse is not what it used to be By Irwin Rubin and C Raymond Fernandez Publisher: Kingsham Press. ISBN 1904235174.£17.95

How did you get your central idea of treating organisations in the same way doctors treat patients?

One morning I walked into the office of Ray Fernandez, then chief executive officer of the Nalle Clinic in North Carolina, to take him to lunch.He said he was dictating weekly notes for a record and would be a moment.

I knew he had given up seeing patients to become a full-time CEO several years before. It turned out that, as a way of ensuring he acted with integrity, from his heart, he had unconsciously positioned himself as the attending physician of this organism called the Nalle Clinic.

Every week he dictated notes, which no-one else saw, tracking the progress of his 'patient'. The work I am doing in South Tees, Norfolk and Devon has convinced me that there is nothing in the NHS structure which makes this concept less relevant to the UK.

How do you know if an organisation is being handled like an organism?

One thing to look for is how it handles the need to get rid of some employees.

In one sense That is no different from a major operation for a patient. I have seen examples of organisations laying people off in a very inhumane way as if that has no impact on the people who remain - the body, as it were. The trauma will last for years.You might get away with it in a car dealership, but not in a healthcare organisation.

A lot of HR procedure is aimed at the people leaving, very little at those staying.

I worry about situations where chief executives suddenly disappear - That is like ripping someone's heart out, putting a new one in and expecting no impact.

It is not about the procedure itself, which is pretty simple - It is partly the pre-op but mostly about intensive care afterwards.

You also wouldn't do this without a lot of talking both with the patient and their family.

In many organisations, the exact opposite is true under the guise of 'let's not get everyone too upset' - in effect you have a patient who's not fully informed.

Can you say more about communication and feedback?

There is a trend towards so-called 360 degree anonymous feedback - to me that is creating the wrong culture. The 'patient' should get information direct from the 'physician', face to face. People say you can't give direct feedback because people will not be honest - that is the fundamental problem of an organisation with low levels of trust.

That said, my personal experience in the NHS is that people are absolutely hungry for direct feedback, for the opportunity to develop the necessary trust to sit down and have a caring conversation.

In the face of difficult outside influences, trust managers have two choices - they can fight with one another or they accept they cannot change those outside influences and focus on what they can influence, which is the way they work together.And the case for the latter is even stronger when thinking about a health community.

Where do doctors come into this?

In the early stages of an organisation's development, doctors protect their own interests. In a stage-two organisation, physicians see the benefit of having a voice in managerial processes - which is where the NHS is with the consultant contract. But the fundamental jump is where both managers and clinicians understand that management is proactively related to quality of care, not just the dollars.

Managers need to stop talking just about efficiency and cost effectiveness.When doctors get together, as they have done in the UK, and buy their own hospital as the only way they see of protecting their practices, they are taking the right action for the wrong reason. A problem in the US is you have small numbers of clinicians making a lot of noise and employers are not prepared to take the short-term income hit by dispensing with their services.

One of the problems in the UK is that doctors who do take managerial responsibility are not financially rewarded to reflect how important they are told it is.

What are the indicators of clinical buy-in?

You know you are getting there when you have a performance review for physicians that takes into account more than peer review of clinical case performance - There is a series of behavioural standards, standards of conduct, that they are held accountable to. In the strongest US organisations, you see that. I haven't seen it in the UK.

What makes a good chief executive?

It is the difference between being a map reader and a map maker - you need map makers these days.

The information flow needs to be continuous in order for you to be able to adapt quickly. Part of that is knowing when to forget about rank.

I remember watching Israeli soldiers work in the 1970s. They had the attitude: 'When we are planning, it is a crime not to state your opinion openly.'

When the plan, the map, has been made, they went back to the hierarchy.Most managers are not good at that.

Irwin Rubin will be speaking on organisational change at the NHS Confederation conference, Birmingham,2325 June.For more on his work, visit www. tlcmattersltd. com