Lessons from London
In 1968, the London Underground had a problem. They had several different types of trains that were servicing the underground railway. Consequently, the platforms where the public stood did not always line up with the trains. Some trains were several inches taller and some were shorter than the platform. A few platforms were built along curves in the track. Since the train cars are straight, there could be quite a gap between the train and the platform. As a result, people were tripping, falling and getting hurt. Their solution to the problem was to launch the now famous campaign warning people to "Mind the Gap". The phrase was played every time that a train arrived at the station. Signs were placed everywhere. It may have worked for the London Underground in the 60's but organizations that use this strategy today are setting themselves up for a disaster of epic proportion.
The New Orleans Levees: A Catastrophic Gap
Following Hurricane Katrina there was a massive investigation to try to figure out why the levee system failed. One of the key findings revealed that often times the places where the levee failed were at the junction between two different jurisdictions. In some places the wall was at least a foot taller than the adjoining section. (As if the water knows it is just supposed to raise up only where the wall is tall!) These transitional areas were one of the most vulnerable parts of the wall because of how the water flowed when there was overtopping. The water overflow was greatest and most powerful at these points as it spilled over to the other side. The wall’s foundation was eroded and the wall succumbed to the massive pressure and moved forward. Subtly at first. Then it moved just an inch or so. Eventually, the wall failed catastrophically. In one location the breach grew to over 1000 feet wide! Over 10 football fields wide! Thousands were impacted. Lives were lost. The cost was enormous.
After coming home from Katrina I began to ponder what happened to the levee and the fact that the failures tended to happen at the junction between two different jurisdictions. It occurred to me that it was not that much different than the junctions between departments or teams in the healthcare world. How often have you been at work and heard someone say, "That's not my job! That is their job." People tend to stake out their own work boundaries and don't want to go beyond them. It’s New Orleans all over again. One side says that they aren’t responsible and the other said they aren’t either.
One day I decided to try a small experiment. I went downstairs to the lab and asked them, "Hey, are there two or three things that I could do to make your life easier and help you do your job better?" It was the strangest thing. It was as if they had already been talking about it among themselves... for a long time. They enthusiastically responded, "As a matter of fact, we are glad you asked. There are a couple of things….” They gave me a few suggestions that I took back upstairs with me and implemented. It took less than a week before a couple of the lab folks came upstairs in their blue lab coats and said, “Thanks for making the changes. Are there two or three things that we could do to make your life easier and help you deliver better care." I had a couple of suggestions that they took back downstairs and implemented.
It was a fantastic learning experience. Things were much less likely to fall between the gap because we had just narrowed it. The junction between our teams just became stronger. Patient care improved and neither of us cared who got the credit.
”Mind the Gap” is No Longer Enough
Although it is frequently the weakest place, the junction between two jurisdictions or teams should actually be the strongest place in the wall. They key to doing that centers on mindset. There are four types of mindset. Three build weak and vulnerable junctions and only one of them builds strong junctions:
- Those that use the Victim’s Mindset believe that they do not have the power to make a difference and they take whatever they can from others. They don't even think about helping the other team. In fact, they are looking at what they can "get" from the other team. To make it worse, when the wall fails, they expect someone else to take care of them.
- Those that use Manipulator’s Mindset believe that they have the power to do whatever they want and they make it all about them. They love to blame. They will take from the others to make sure that they look good. In the process, both teams can be wiped out.
- Those with the Bystander’s Mindset stand idly by saying that they wish they could help but they don't have any power or the ability to make a difference.
- Those with the Thriver’s Mindset look at the junction and say that they will do whatever they can to make the other team look like heroes. They don't care who gets the credit. They believe that they have the power to make a difference and their goal is to make the other team successful.
Imagine how an organization would be transformed if teams began to adopt the Thriver's Mindset. The walls would be strengthened by teams that were eager to make each other look good. Consider the levee. The threat wasn't the jurisdictions; the threat was the enormous pressure of the water. During these intense times of change in healthcare, it won't work any longer to just point a finger and say "Mind the Gap". We have to roll up our sleeves, jump in and "Bind the Gap".
Healthcare over the years has taken an approach very similar to the London Underground system. For years, the “solution” was not to fix the underlying problem. The strategy was to just to lay the responsibility on the patient (customer). "We know that we have a problem and you could get hurt. Just... 'Mind the Gap'". In healthcare we say, for example, "We know that the wait times in the Emergency Department are long, take a number and settle in. Bring a book. 'Mind the Gap'". This approach isn't going to work any longer. It is time to “Bind the Gap”.
From the Katrina school of hard-knocks: It is much more expensive to repair the wall after the storm.
Patients are in the driver seat like never before. They are paying an increasing amount of their own healthcare expenses and therefore they now have a vested interest in making sure that they get the best deal possible. After all, people are now able to buy laundry detergent without even leaving their chair. They receive it in two days — with free shipping. We have now entered the new world of the retail-ization of healthcare. The patients have become frustrated and impatient. If we don't address these issues, the soil is fertile for someone else to swoop in an do what Uber did to the taxi world.
If those of us in traditional medicine want to continue to make a difference, we are going to have to toss aside the old slogan of “Mind the Gap”. It is time that we truly put patients first. It is time that we rally behind a new slogan: "BIND THE GAP"!
People that BIND THE GAP:
- Believe they can make a difference.
- Put others first.
- Don't care who gets the credit.
- Care about the big picture.
- Ask great questions of other teams like:
- "What keeps you up at night?"
- "Can your team see any weaknesses in the way our team operates?"
- "Is there anything that I (we) can do to make your job easier?"