Chapter 04: The Challenges of Chaging Institution Culture

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Chapter 04: The Challenges of Chaging Institution Culture

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In this chapter, Dr. Balch and Ms. Sollenberger discuss several facets of their work changing the culture of the Division of Surgery. Ms. Sollenberger begins by commenting on her role in managing faculty conflicts, noting that it was surprising how quickly conflict would fall away when parties began to talk to one another. She tells how she reduced resistance to a needed change when it was discovered that patient satisfaction was very low among head and neck patients. Next, Dr. Balch discusses the Division’s use of standardized tables to determine faculty salaries. Ms. Sollenberger recalls comments from faculty that demonstrated how MD Anderson’s old culture of surgery lingered and prevented change. Dr. Balch talks briefly about difficulties created with staffing during the AIDS epidemic. Next, Dr. Balch explains that in 1991, MD Anderson was dominated by a state civil service mentality that needed to change so employees felt they were employed by a private institution that was state supported and was devoted to patients who drove the business. This leads to more discussion of the patient focus of multi-disciplinary care clinics. Ms. Sollenberger explains that when the Alkek Tower and Ben Love Clinic were being designed, the planning team held meetings to get patient feedback –an unusual move for a cancer center at that time. Dr. Balch talks about the creation of the patient coordinator role to help patients with scheduling.

Identifier

SollenbergerD_01_20190709_C04

Publication Date

7-9-2019

Publisher

The Historical Resources Center, The Research Medical Library, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

Building the Institution; Institutional Processes; MD Anderson Culture; Working Environment; Professional Practice; The Professional at Work; Collaborations; Leadership; On Leadership; Building/Transforming the Institution; Multi-Disciplinary Approaches

Transcript

[REDACTED]

Tacey A. Rosolowski, PhD:

Well I wanted to ask, is your view similar in terms of how things were flowing, and were there moments when you were massaging this process of getting people into collaborative connections?

Donna Sollenberger:

Sure.

Tacey A. Rosolowski, PhD:

Well tell us.

Donna Sollenberger:

Well after our divisional executive committee meeting, you can sense who wasn’t really onboard even if they didn’t speak up. So usually after those meetings, I spent the next couple of days going around and talking to all the department chairs.

Charles Balch, MD:

And the department administrators.

Donna Sollenberger:

And the department administrators. That was another challenge. Yeah I forgot about that.

Charles Balch, MD:

Also one of the connections is, Donna related to the department administrators and that created another layer of people who would support some of these activities.

Donna Sollenberger:

And we met.

Charles Balch, MD:

She supported them.

Donna Sollenberger:

And we met together as a group as well, with the department administrators. And I think that—so I would meet with some of the chairs that were not necessarily onboard and hear their concerns and try and think of well, yeah, but you know, think about this point of view. So we’d have just some good conversations that weren’t very threatening. A lot of times I find, still do, you may not get agreement at that moment, but if you plant the seed and let smart people think about it, they’ll come back and say, “Well, you know that probably isn’t …” Or sometimes we can come up with a solution that meets all the criteria. I remember an example of that was—there was so much. I mean the patient satisfaction in the Head and Neck Clinic was awful. So I finally thought okay, I’m just going to spend a day down there. So I showed up at I don’t know, seven-thirty, quarter ‘til eight, the waiting room is packed. I mean standing room only. Do you remember this?

Charles Balch, MD:

Yeah.

Donna Sollenberger:

And I thought, what on earth? And then you would see it would slowly trickle out at noon, and then by one o’clock it’s packed again. So I asked the schedulers. I said, “I mean our people, do they all come earlier?” They said, “Oh no, all of our appointments are either at 8:00 a.m. or 1:00 p.m.” It might have been eight-thirty, but eight-ish. I said why? These people have to sit and wait, and they said it’s so the doctor will always have a patient to see. I remember going back horrified and said that I had to go talk to Dr. Goepfert [oral history interview], who was Head and Neck Surgery, and he was very skeptical we could do anything differently. It was really important, a doctor’s time was precious, of course it is, and they didn’t want any break where not everybody—

Charles Balch, MD:

Yeah.

Donna Sollenberger:

So you’d schedule everybody at eight in the morning and then there was always somebody there for the doctor. So I talked to him about how it could be done differently. I asked would he allow us at least to pilot it with one or two of the doctors, and he did allow that. I think he didn’t participate but there were a couple of them. I don’t remember who we did, and they actually said, “Oh my gosh, it works and the patients are happier.” So we got—it’s that kind of pointing out a problem, planting a seed and then saying—I even said to him, just let me try it, if it doesn’t work after –say, give me two months. But if it doesn’t work we can go back. That will be fine. And it worked and so everybody changed.

Charles Balch, MD:

So Donna, one of the other things I remember at the division level had to do with salaries and level of compensation. Do you remember we took the position that people would be paid, at their entry, at the 50th percentile of the AAMC tables for that specialty? And that they could work up to the 75th percentile while they went on to the next level.

Donna Sollenberger:

Correct.

Charles Balch, MD:

I remember the context of this is a department chair from another department was complaining the neurosurgeons were paid too much. My answer was, well then they should have been a neurosurgeon because we’re paying them based upon neurosurgery faculties. But we had to use a standardized table, which I think is still being used today. So we’re not using one-off decisions, and we could justify it by saying here’s the table for the 50th percentile. We used mixed public and private charts, because those are very complicated tables. But we set as our standard for setting salary for the whole division, that we would use the AAMC standards and that we would peg the entry at the 50th percentile, using the table for the mixed public and private institutions. But it’s just another example of having things that are standardized, so that you depoliticize things of why are you getting paid this. You have a reference point to go to that’s outside the institution, that made it, I think more politically neutral.

Donna Sollenberger:

You know, you triggered a thought. This is, I guess a more global thought, but there were evidences that I was surprised by, early on. Even though you’d been there since 1986, before that it was Dr. Hickey, who was really good friends with Dr. Clark. I was struck by how much the old culture could still prevail and how hard it is to change that culture. I can remember we were having trouble hiring certain kinds of physician, well anesthesiologists. And after you and I were wracking our brains, and why can’t we—and then they said, “Well, you know…” We said look, your offers are not at the assistant professor 50th percentile, and they said, well we can’t do that. Do you remember this conversation?

Charles Balch, MD:

Yes I do. This was Hollis Bivins, who came from the military, whose idea of salary should have been the military level salary.

Donna Sollenberger:

He said, “Well I can’t do that, I can’t hire someone just out of training as an assistant professor.” I said why not and he said, ‘They won’t let me.” I said, “Who?” I said, “Who are they,” and he said Dr. Clark. I remember thinking, “Oh my gosh, it is, it was the problem.”

Charles Balch, MD:

Who hasn’t been president for ten years.

Donna Sollenberger:

But it just shows --and especially in great organizations with iconic leaders. I think it is hard to change everybody, especially if they—I mean for them to change. We finally got through it, and he was really tickled to death he could do that, but it was interesting to me. How some things just become urban legend, and so it’s hard to change the culture.

Tacey A. Rosolowski, PhD:

There’s that quip and I have no idea who said it but it’s “culture eats strategy for breakfast.”

Donna Sollenberger:

Every time.

Tacey A. Rosolowski, PhD:

But you don’t even know when you’re pushing up against culture until you have one of those ah-ha moments.

Donna Sollenberger:

That was exactly right, because we could not figure out why, and we were dying because we had more surgeons and we needed more anesthesiologists.

Charles Balch, MD:

Let’s talk about that. If you remember, at the time with the AIDS infection we --on any given Monday, we did not know who was going to show up for work in anesthesia, because we had a large number of both physicians, but nurses anesthetists. A number of the nurse anesthetists especially, were dropping out with AIDS. This is at a time we didn’t have treatment, and people were getting sick, and many of them were dying. So it was really an unsettling time of do we have enough anesthesiologists to serve the surgical community and their operative load.

Tacey A. Rosolowski, PhD:

Why were the nurse anesthetists in particular, vulnerable.

Donna Sollenberger:

I don’t think that all the universal precautions had been put out there. Yeah, it was how to handle patients with evolving—

Charles Balch, MD:

It was one of those things we had to keep quiet. If the patients knew that the person giving them anesthesia was an AIDS patient and they might object to it, but we got through it all, but I do remember at that time, there was so much. We took care of so many AIDS patients because they had Kaposi sarcoma, that Dr. LeMaistre actually had a discussion about forming an AIDS hospital, because we had more experience than anybody else, and rather than having that specialty in a cancer hospital doing something different. How different things are now.

Tacey A. Rosolowski, PhD:

God no kidding.

Charles Balch, MD:

We didn’t need an AIDS hospital, any more than we need iron lungs for polio victims, because of advances in therapy. So one other thing just to talk about change and the resistance to change that I remember. We started having, instead of having typewriter-driven operative notes, we had an electronic operative notes, and the computer would only allow us to have the signature on the left-hand side. So you know my story?

Donna Sollenberger:

Yes.

Charles Balch, MD:

Charles McBride always signed his name on the right-hand side at the bottom because that’s where the typewriter put it. So a new electronic version came out, and the operative note --his name-- would be on the left-hand side on the margin. He would sign his name where he had always done it for years, on the right-hand side. I only say that as a story to show sometimes the difficulty of changes comes down to that level.

Tacey A. Rosolowski, PhD:

The community level, yeah, yeah.

Donna Sollenberger:

Yeah, it is, and there was a lot of culture change going on in that time period.

Charles Balch, MD:

So maybe one thing we should talk about is, when I came --and I think around the time you came-- we were still in the era of a state-of-Texas owned operation. The employees, the culture was more of a state-of-Texas-civil-service mentality. Part of what I think we all changed, including with Donna and the other division heads, of saying we need to act as a private institution that’s tax supported, not in the civil service mentality. That change in culture, which took several years, including changing of the legislature to free us from the state of Texas regulations, is something I still see today. You cannot walk around MD Anderson and begin to look like you’re lost without somebody coming up and saying, “Can I help you?” I think that’s part of it. Most people at MD Anderson do not believe that this is owned and operated by the state of Texas, because it really is very service-oriented, and you among others, really were responsible for changing the culture among the staff.

Tacey A. Rosolowski, PhD:

How did that happen, how did you folks work on that?

Donna Sollenberger:

[Laughs] One person at a time. Now, I mean that setting the expectation that we had to be sensitive to our patients, that was going to be our future. We did a lot of things. We changed access and who could accept of patients. They used to all be all over the department, so we consolidated that, so all appointments went through the access center. We may have called it something else at the time. So really, I think demonstrating that patients should be driving our business. It goes from the appointments, from the surgeons, to how appointments are made, and then once a patient gets there, really listening to the patient voice. And I think really, the story of Eva following her patient and how many miles it was … You know things become urban legend and that story says to people oh, the patients are important.

Charles Balch, MD:

People still quote that story.

Donna Sollenberger:

I know, and we should organize in a way that our patients like. So we started … When we were planning the clinic and the Alkek, was it the Ben Love Clinic and the Alkek Tower, we did something that was not really heard of. We started convening groups of patients and going over the plans and saying, “What would you do differently, what do you want, if we have a new facility what would you need?” We involved the Anderson Network folks who were all former patients. So I think the fact that we started including patients in a lot of our planning and a lot of our operational change initiatives --where we would have groups that were convened to work around something-- started communicating to people that the patient voice was necessary, and we hadn’t had enough in the past.

Tacey A. Rosolowski, PhD:

How common was it in cancer centers, to do that kind of involvement of patients?

Charles Balch, MD:

At that time not very much. It was really more around the doctor. I think the cultural change was, instead of having the patients come to the doctor, the doctors come to the patients. So the patient goes to one site, and the specialties all come to the patient. That was a fundamental shift in the culture that occurred before any other cancer center that I know of in America.

Donna Sollenberger:

Well, and I remember speaking with a woman whose son was a really prominent Houstonian. I don’t know if I should tell it, I mean with the name; I would but I’m not sure. Anyway, and I was talking to her at a party one time. It wasn’t even MD Anderson related. I told her where I worked, and she said I would never go there. I said, oh, I said, I’m interested, tell me why. Well, her daughter had been diagnosed with cancer, and she was an adult daughter when she was diagnosed. So this was a woman, who was probably then my age, she said it was just a horrible experience. She said you waited all the time. I mean you’d go in, it didn’t matter when your appointment was, you’re still getting out at five or six. It’s confusing where to go, the place looks like a bus station in the waiting rooms and the chairs are uncomfortable. I just thought, “Gosh, for treatment, probably the best cancer center in the world, and people aren’t coming because of how difficult we are to access, how difficult we are to navigate and how generally unfriendly we are. And, by the way, I mean your waiting rooms, your public spaces, are terrible.” I started talking about those stories. We had our Changes and Challenges, and anybody could come. I can’t remember if I did that monthly.

Tacey A. Rosolowski, PhD:

Is that a kind of meeting you would have, Changes and Challenges?

Donna Sollenberger:

And we would start talking about it in all those meetings, and then we’d follow up with some email communication. But started talking about how important our patients are to us. Everyone who comes there as a guest, we need to treat them like that. But we did. [ ] We did lots of different things that I think finally struck the chord with employees that this is important. Then we caught people in the act of doing something kind and we would talk about those.

Charles Balch, MD:

The other thing I remember is we had the caregivers, the patient care coordinators who would meet a patient at the front door and they were deputized. They had our number, and if there was some delays or some problems, they reported to us and that also gave us real-time feedback.

Donna Sollenberger:

That’s for new patients, yes.

Charles Balch, MD:

Yes, for new patients, but it also gave us information about the issues patients face on the first day.

Tacey A. Rosolowski, PhD:

Who did they report to, what was that?

Donna Sollenberger:

What was her name, I can’t think of her name. She’d been Michael DeBakey’s nurse a hundred years before that.

Tacey A. Rosolowski, PhD:

So this was just a person who took all that feedback.

Charles Balch, MD:

Well, no we had a series of people.

Donna Sollenberger:

She managed them.

Tacey A. Rosolowski, PhD:

I see.

Charles Balch, MD:

Leslie Bean was one of the persons I remember, but I don’t think she was a manager.

Donna Sollenberger:

She wasn’t. Oh, I can see, her and Drew von Eschenbach worked for, and Bill…

Charles Balch, MD:

But the point was we had a whole layer of people whose job it was to meet new patients at the front door and escort them during that day so they could make sure that they were synced on time, and if there were any problems, they knew who to call to work out the problems.

Tacey A. Rosolowski, PhD:

Very cool.

Charles Balch, MD:

We don’t have those now. I don’t think we need them because things have gotten so much better, but it was one way of kind of overriding the system and giving them a more personal level of care and their first impressions when they came on their first day.

Donna Sollenberger:

[REDACTED] what I was struck by --that the Outpatient Services were really patient-centered and the people were super friendly and helpful and all of that. There was still, the inpatient side was still felt like more physician-centric, and the staff responding to the physicians, not so much to the patient. So I think that you work on things and you hope they stick, but unless someone who succeeds you also has that same kind of emphasis, eventually you can slide back to where you were. I know the other thing we did. We said we were going to give—I forget what we called it, it was a team award. So if we met our budget and we met a certain threshold of patient satisfaction, it triggered a payment to every employee. Do you remember that?

Charles Balch, MD:

Yes I do.

Donna Sollenberger:

I remember the first time we did it, we had all the administrators with these tables of a box of A, B, all the way down the alphabet. The employees would come up, and we’d give them their check, and shake their hand, and tell them thank you for helping MD Anderson succeed. We tracked that performance every month, what the patient satisfaction was and how were we doing financially, because David Bachrach would do that. So you started putting measurements out that mattered, and right then the two things that mattered were our financial position --because we were going through managed care, this was later, I was in the hospital side then-- and then patient satisfaction. I think just starting to measure that, and report on it, and help people see there could be an incentive around that if we performed well. So I still use that.

Chapter 04: The Challenges of Chaging Institution Culture

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