When my hospital instituted barcode scanning for all medications, every nurse attended an orientation on scanning. It was given by people who freely made sarcastic and dismissive remarks about nurses' challenges in using the technology. The aim seemed to be to teach and to mock, in equal measure. I still feel angry when I think about it. Reading Patients Come Second: Leading Change by Changing the Way You Lead (An Inc. Original, 2013) validated my anger at the fundamentally bad management practices that this particular incident revealed: the people providing care were not valued.
I rarely read books written for managers, but Patients Come Second was a pleasant surprise. It offers one very important idea about improving health care-namely, that a hospital must put employees' health and satisfaction first, because if staff feel engaged, respected, and valued, they will as a matter of course deliver good care.
Authors Paul Spiegelman and Britt Berrett, who are both health care chief executive officers (CEOs), begin by acknowledging that "there's a crisis going on in health care, and everyone is looking in the wrong places for a cure." During the COVID-19 pandemic, nurses saw this play out over and over again, as short-staffed units tried to squeeze more work hours out of their already exhausted RNs, brought in travel nurses and paid them five times what the staff nurses made, or did both. In many large hospital systems, there seemed to be an institutional reluctance to improve retention by increasing nurses' pay and improving their working conditions. Instead, hospitals focused on keeping labor costs down, and ended up chronically understaffed.
Spiegelman and Berrett introduce the idea of "transformational leadership," which they also call "purposeful leadership." Such leadership is focused on the actual mission, vision, and values of the health care organization. The authors also assert that in every successful company, "financials come third" in importance, after staff and patients. This approach works because a company will succeed financially if its workers are engaged.
How, then, can health care organizations put workers first? The authors offer compelling examples. For instance, Spiegelman explains, his company's website has a link to a digital forum, "Ask Paul," where employees can ask questions anonymously. The questions are often quite specific, such as "When is the toaster in the breakroom going to be replaced?," and show how workers' concerns usually differ radically from those of CEOs. Yet addressing them matters. In being open to employee feedback, the company is able to lift its workers' morale and strengthen their engagement. The authors also urge managers to fire difficult employees, pointing out that "whiners, losers, and jerks" sap time and energy better spent on employees who are engaged and do good work.
The book would be more persuasive to health care managers if the authors had included more data showing that focusing on staff invariably improves patient care and thus leads to "the financials" working out. But the idea that all health care workers add value to their institutions and deserve respect is radical. I urge staff nurses to gift this book to their managers-anonymously, if necessary-to show them that treating all employees equally well can yield unexpected upticks in the quality of care given.
It's worth closing here by returning to the inspiring ideal behind the ideas in Patients Come Second, in the authors' words:
"It's too easy to pull out a spreadsheet filled with revenues and costs and simply start deleting. That's not leadership-that's just math. . . . The better the members of a team or an organization work together, the better the results will be."
Health care has become big business, but the authors of this provocative book understand that fundamentally it is, and always will be, about the people doing the caring.