Chapter 08: A Leadership Role as a Center Administrative Director

Chapter 08: A Leadership Role as a Center Administrative Director

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Description

In this chapter, Mr. Brewer talks about initiatives he undertook as Center Admin Director Center (1996 – 2004) with oversight of the Ambulatory Treatment Center, the Clinical Translational Research Center, and the Emergency Center. He explains that he was hired to address “a lot of broken processes” and used a “fishbone analysis” (also known as an “Ishikawa diagram”) process well known in process management at that time. He explains some specific issues he had to address and how he went about correcting them. He then lists roles he served before his promotion to a CAD and identifies the dates.

Identifier

BrewerCC_02_20190606_C08

Publication Date

6-6-2019

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; Overview; Professional Practice; The Professional at Work; Leadership; On Leadership; MD Anderson Culture; Working Environment; Multi-disciplinary Approaches; Definitions, Explanations, Translations

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History

Transcript

Tacey Ann Rosolowski, Ph.D. Now, we’re sort of getting into really your role from 1994 to ’96 as director of nursing in the Ambulatory Care Center. So tell me about—you know you’re promoted to this role, really wanted to take on this new challenge. What was your mandate from the institution, We’re giving you this, this is what we want to you to do, but then did you have your own ideas for stuff you wanted to do? Give me the lay of the land about that.

Cecil C. Brewer, RN, BSN, MS:

I was recruited to transition from inpatient to Ambulatory Treatment Center by Dr. Ed Rubenstein. He was the medical director for the Ambulatory Treatment Center. The treatment centers were highly complex. They were having tremendous amounts of challenges going on. They were really looking for someone who’s good at organizing and communicating effectively with physicians. Tacey Ann Rosolowski, Ph.D. What were the challenges that you were—that were problematic?

Cecil C. Brewer, RN, BSN, MS:

Well, some of the issues were that there was some—there was nurse turnover issues. The nurses are not satisfied with their roles and not satisfied with their jobs if you will, and there were issues with budget. There were issues with physician relationships with the administration and with some of the departments because the Ambulatory Treatment Center had its own administrative arm, and there was relationship issues. So my challenges were strengthen relations—strengthen and building the relationships, strengthen the organization, strengthen recruitment, and getting staff to pull together as a team. Those were the strengths that I brought to Ambulatory Treatment Center. And it was very difficult because we had a lot of broken processes in place, and the question is—and I still have this picture today—how do you eat this elephant? And it was one (inaudible) at a time. And my approach, which I became kind of “famous” for—this was well in advance of what we have today, what we call performance improvement. I used the performance improvement tool, a process analysis tool are introduced to the ambulatory treatment centers and call it—and we called fishbone analysis. And basically what I did was to get all of the various team, their leaders together because—let me back up for a second.

You have to understand the breadth and the depth of the Ambulatory Treatment Center. You have a 25-bed unit or chair for short-term chemotherapy, and you’re seeing up to 200 patients a day. You have a bed unit where a patient is lying in bed. These are the more—most acutely ill patient, mostly your hematology patients, your bone marrow transplant patients, your leukemia patients, lymphoma patients, and that’s a 25-bed unit. Then, you have Station 19, which is urgent care. Now, you got all of this—all these up under one umbrella. How do you organize that, and how do you get work done where people or staff are communicating effectively, working as a team, and practicing safe—safely? That is very complex. And so how do you approach it? First, you have to understand the problem, what the problems are and then you have to come with a plan on how to address these problems. And we would work with my medical director, Dr. Rubenstein and his administration. I’m the administrator for nursing in that area with my nurse managers, my head nurses at that time, my clinical specialists, my nursing instructors whom they would work with the staff on how do we better improve our image. Tacey Ann Rosolowski, Ph.D. Now, the fishbone analysis that you refer to, where did you get that process from?

Cecil C. Brewer, RN, BSN, MS:

The fishbone process is a well-known process analysis in the management or in the management—process management. A lot of it is built of industrial hygiene—industrial hygiene management, and all you’re doing is taking a linear view of problems and lining them up. And as you go down this list, it’s like a bone, you can see where these different issues come off. Tacey Ann Rosolowski, Ph.D. Yeah, they’re all coming to—yeah.

Cecil C. Brewer, RN, BSN, MS:

And then from that point, you have to start dissecting each one bone by bone to see how they all integrate back to the spine and then the end point with the patient always being the center of attention and— Tacey Ann Rosolowski, Ph.D. What was the arc of solving that problem? How long did it take before you felt there was impact?

Cecil C. Brewer, RN, BSN, MS:

What was the arc, and how long did it take? The arc was pooling people together on a common project that they all had buy-in and that their input were being respected and that—and where you demonstrate, that is that you document what they—and you document what everyone has to say. Tacey Ann Rosolowski, Ph.D. Were there people who were resistant to this process?

Cecil C. Brewer, RN, BSN, MS:

Oh, yes. Yes. I would say that probably in all the processes that I’ve worked with, there has been some type of disagreement, but we set the expectation high, we set the parameters, what we’re going to tolerate, what we’re not going to tolerate, and we put our energy into those who are going to have a positive force. And you make hard decisions as you go along, and for those who don’t want to participate, you help them to find a place where they might better fit. Tacey Ann Rosolowski, Ph.D. What were some of the hard decisions you had to make during this process? I mean I’m asking not for—I’m asking to kind of understand the complexity.

Cecil C. Brewer, RN, BSN, MS:

Well, some hard decisions—let’s do some clinical analysis: One, where will patients—when patients are directed to come to the Ambulatory Treatment Center to receive a particular type of therapy, how do we manage their time, their appointment times? Everyone would prefer to be treated in the day—daylight hours. We can’t do it. It’s not possible, we don’t have enough manpower, we don’t have enough beds or chairs. Tough decisions that’s—it impacts the patient. Nurses, the nurse-patient ratio, too many patients, not enough nurses. How do we practice safely? How do we provide safe care? The nurse is tired, the nurse is frustrated. Tough decision, where do we get nurses from? Not any nurse, they have to be trained in the care of ambulatory patients and complex chemotherapy, tough decisions. How do we interact with the angry physicians? How do we have collaborative meetings and communication meetings when everyone is complaining, tough decisions. Complaining about what? The appointment time, complaining about maybe a missed—an omission or a commission that may have occurred. Tough decisions on how are you—how do you solve this? Tacey Ann Rosolowski, Ph.D. Interesting.

Cecil C. Brewer, RN, BSN, MS:

Shortage of resources, not enough money in the budget to hire more resources. How do you approach that? Complex, tough decisions, you know. Tacey Ann Rosolowski, Ph.D. How long did it take before some of those knots were untied and things smoothed out a bit?

Cecil C. Brewer, RN, BSN, MS:

We called them bottlenecks. In the fishbone analysis, we go, “Where are the bottlenecks? What’s stopping—what’s bottlenecking the system from doing point A?” I would say it’s a continuous process. I would say the major components, we were able to outline within six months; we get them outlined. Tacey Ann Rosolowski, Ph.D. Wow, I’m surprised. (laughs)

Cecil C. Brewer, RN, BSN, MS:

And start—well, remember, you’re dealing with patients. We’re dealing with people, we’re dealing with lives, we’re dealing with—a lot of our patients don’t have that long to live, and we’ve got to get them into treatment. We have to get them into the flow. We have to have nurses who can provide the safe level of competent care, and administrative—in administration, we have to support them. We don’t have a lot—we can’t study just to be studying. So once we identified all the problems and the bottlenecks, we started eating the elephant one step at a time. Some things we were able to work on immediately because it was simple, and we moved from simple to complex. Other things, we looked at and we placed them in this box to the left and say, “We’ll work on this three months from now.” So we looked at what we—what the problem that could be solved immediately. One of the techniques that I’d always use in working with projects and people is to show immediate success. Find something very simple that can be accomplished but has tremendous impact. If nurses are complaining, “We can’t—” I don’t know —“We don’t want—we can’t get to lunch on time” or “We’re never able to get lunch” or something like that, “We always had to work during lunch,” how about this, how about the director show up one day with packed lunches for everybody? I can’t do it every day, but I’ll surprise you on Friday. Tacey Ann Rosolowski, Ph.D. Yeah, it’s a big statement.

Cecil C. Brewer, RN, BSN, MS:

One of the things that I did was I always kept a lot of fruit in my office, so if I saw a frustrated nurse who was not able to make it to lunch, I just grab me an apple, and I’d walk up to him or her, say, “You get the apple today.” We don’t have to exchange words, we don’t have to say why, it’s just here’s a compliment to you. Little, simple, small steps make a difference, not the big complex— Tacey Ann Rosolowski, Ph.D. Well, those are enormously human gestures too. I mean, I’m seeing you as a person, it’s—that’s a lovely gesture of caring too for your people.

Cecil C. Brewer, RN, BSN, MS:

[00:54:21 And I think we identified over 100 bottlenecks in this project, and we divided them into different categories. And then within those categories, we divided them into complexity, and you form task forces, and you send those task forces out to come up with solutions. And you involve the staff, the people who actually do the work. It’s not top-down management anymore. It’s a collaborative team approach but realizing that the top leadership has to make the tough decision when it comes to the—you know. Tacey Ann Rosolowski, Ph.D. Right. So during your two years there, what did you feel that you had accomplished as director?

Cecil C. Brewer, RN, BSN, MS:

Two years, when? Tacey Ann Rosolowski, Ph.D. Ninety-four to ’96, you were director of nursing there for the Ambulatory Care Center.

Cecil C. Brewer, RN, BSN, MS:

No, ’94 to ’96, I was the interim director for medical onco—for medical ICU and surgical ICU. Tacey Ann Rosolowski, Ph.D. Oh, okay. I had that differently from your CV. I’m sorry.

Cecil C. Brewer, RN, BSN, MS:

It could’ve been a typo but from ’90—let me back up for a second on my CV for you. Tacey Ann Rosolowski, Ph.D. Sure.

Cecil C. Brewer, RN, BSN, MS:

When John Crossley came in 1994, there were tremendous issues that were occurring in the medical intensive care units, in the surgical intensive care units. There were some issues with relationships and turnover and care, etc., and I was asked to step in on an interim basis as the director for those units. Tremendous amount of high-level interventions going on and so there was a need to—for new leadership. Tacey Ann Rosolowski, Ph.D. And again, the units that you had control over were?

Cecil C. Brewer, RN, BSN, MS:

In early ’90s, I had units like Five West, so just— Tacey Ann Rosolowski, Ph.D. No. I meant when you were in this, ’94 to ’96 role, yeah.

Cecil C. Brewer, RN, BSN, MS:

Oh, ’94 to ’96, I had—my primary responsibility that I had, then I took on that interim role for Surgical Intensive Care, SICU and Medical Intensive Care, MICU, and those were two units of—MICU was located on Three West and surgical ICU was located on Four West. The combined staff from those two units was probably close to about 150 to 200 staff members. Tacey Ann Rosolowski, Ph.D. Wow. Okay. And so this was in addition to the role that you were serving at the time.

Cecil C. Brewer, RN, BSN, MS:

Yes. Tacey Ann Rosolowski, Ph.D. And that—oh, wow, so (laughs) you were a busy person.

Cecil C. Brewer, RN, BSN, MS:

Well, yeah, I think you can be busy—as a leader, you can be busy as organized as you are. If you’re chaotic in your organization, no one’s going to hire you as a chaotic leader. But I was chosen to go in and to try to reestablish the line of communications, build some relationships, get the nurses back on point as far as how they work as a team and let the nurses do what they are hired to do, that is take care of the patient.

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Chapter 08: A Leadership Role as a Center Administrative Director

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