Thursday, January 04, 2018

Inefficient Meetings

Inefficient meetings today. On a geriatric or forensic unit, people are not discharged quickly.  Yet we are required to have frequent meetings specifically discussing discharge anyway.  The "what's happening with discharge?" portion often doesn't change: "He can't even leave the building until he has his next Gibbs Hearing." "We won't be able to get her in anywhere as long as she's throwing urine and feces at anyone who comes into the room." We are supposed to pretend for the sake of the record and to keep the civil liberties lawyers at bay that something is actually going on, and that it is proceeding to a discharge in some orderly fashion.

It's actually not as crazy as it sounds.  If you didn't make us pretend and find something that we can say we are doing, these impossible discharges would take two years instead of one, at considerable expense to the state and unfairness to the patient. Still, for someone who is just covering for three days, as I am, it is easy to contrast the way the meeting proceeds on those units with how they go on the childrens' and acute care units. In those meetings, we talk about actual discharge stuff: Have they gotten a Bridge Program voucher to get into housing? No. Why not? They need a waiver because he's got a criminal record. How long will that take? I expected it this morning, but Chip is out, and he's the only one who can do it. So tomorrow? Probably.  In the meantime, I'm going to call landlords and get an actual Nashua apartment. Nashua is a black hole for apartments, though, right? His aunt is a realtor and he's got money up front. Praise Jesus (this said facetiously). I did.  For three minutes straight about an hour ago (said sincerely).

But on the long-term units everything eventually turns into discouraged, endless tales of how bad things were yesterday, and how irritating and disobedient the patients are. "We have this ongoing problem. Patient coffee is at 10:30.  Michael comes up 20 minutes early every day and asks the staff who are preparing the 10:30 coffee and snack to get him his own coffee then goes on his privileges. So there's this cascade effect that everyone wants their coffee early because they see Michael getting it..." Just stop. This is not a Michael problem, this is a staff problem.  Some staff give him coffee and the others don't want to and feel put in a bad position.  Michael will always do this.  (I can vouch for that because he was a year behind me in grammar school and was like this 55 years ago. Even before he tried to murder a guy at Dunkin Donuts he wanted the rules bent for him.) The supervisor will not insist that people either be flexible and live with it or stick to the rules and live with it. By numerous trails, week after week, the line staff wants the doctor, with the support of the OT, social worker, and whoever else is sitting there to insist that a) those other inflexible bitches give coffee other than at 10:30 or b) those enabling, spineless cowards be made to stick to the 10:30 coffee time.

This repeats for all 12 patients on the team.  He won't.  She never. Last night he was on the phone to his wife and I told him that he couldn't talk like that to her and then he said...(six minutes of blow-by-blow pointless conversation. I focus really hard at what I can offer as an outsider coming in, and used to think that what I could bring was clarity. I used to think it was working great, because literally everyone on the team would come up to me afterward and tell me how grateful they were that I had brought clarity to the discussion of patients 4, 7, and 9, that they had been trying for weeks to get across. Or (next up) the clarity I had brought to the discussion of patients 2, 5, and 11. Which they had been trying for weeks to get people to see. Rinse. Repeat.

But ultimately, it's one person who is dominating the complaint department, using this as her opportunity to complain about this unit's methods, or the hospital's methods, or the whole mental health system in this state, or the legislature, or attitudes in this whole friggin' country... at which point it either becomes a complaint about Trump/Republicans/Conservatives, or occasionally political correctness so that you can't say what is really going on...

It's easy for me to scoff, but this is just what people do when they have to manage bad situations because there really aren't any solutions.  I get to see it in stark relief, because these are situations that really don't have neat solutions that people on radio and TV can pretend exist. It's just going to suck, and we might make them a little better and squeeze them into some passably better situation that costs everyone a lot less.

To do this right would cost about five times as much, and we're already one of the big-ticket items in the state budget.  You get that, right?

The same inefficiencies occur in your meetings, but less obviously. It's just human nature when faced with the endlessly discouraging.  The service I provide here is that if your meetings are going inefficiently, it might be victims unable to contain their narratives of how hard this all is, disguised in politer language because they know that just won't fly.  But you might be able to sense that this is what is really happening underneath: a management problem disguised as a budget, recruiting, regulation, or vendor problem - because management doesn't really have a way to make this better, and it just sucks the fluoride out of the teeth of the people answering the phones or dealing with the public, or trying to train pigs to sing.


Sam L. said...

So. Are you in Hell, or Purgatory? Embrace the power of AND? Are you fighting the current or drifting with the current? Just trying to stay sane and get to retirement?
I guess there's little or no point in answering any of these. If you did something good for someone, you had a good day.

Assistant Village Idiot said...

I retired a year ago. I come in about 8 days a month for coverage - I am not a fixture on any team, and actually, haven't been for three years.

I get the job for the patients, the families, and the records done without much effort at this point. Improving team function is the one place where I really think I can make a difference because I am non-threatening. I was always good at improving whatever team I landed on. I try to draw on that now. I have no way of measuring whether I am succeeding, but I'm pretty sure I'm not making it worse. Today I talked humorously about what we can fix and what we can't, and even gently introduced the idea that sometimes it is staff-sabotage, not bad patient behavior, that causes this.

One has to be careful, though, and not just because offending will shut the operation down. Personality disorders elicit staff-sabotage without even trying, which gets the first shift battling the second shift, or the nurses battling a particular doctor, or everyone refusing to acknowledge who the obvious pathological staff member is. That type of patient makes their internal conflict external and fought out by others as natural as breathing. If that is what is happening, then an entirely different type of clarification is needed.

Complicating this are narcissistic doctors, nurses, psychologists, etc, who are determined that they must be the only one allowed to solve the problem, therefore undermining anyone else's solution. I am sometimes good at manipulating male clinicians into treating my solution as theirs, which they then insist on. I could get female clinicians to stop sabotaging other staff, but never did figure out how to convince them of my plan.

It's much more restful to go to the units that don't have these problems.

Texan99 said...

I often find meetings unendurable because no one seems quite sure whether we're having a brain-storming session, a fat-chewing session, a group bonding experience, or a parliamentary procedure that is designed to result in formal approval of certain actions that can't go forward otherwise. If the meeting is in any of the first three categories and isn't satisfying for its own sake, the only defense is to have a buzzer go off when it's clearly OK for anyone to get up and leave. I once got stuck in a 14-hour meeting; I think the guy who was responsible just liked proving he could trap a lot of people in a room.

In recent years I've resolutely declined all volunteer work that entails meetings. I've made a few exceptions: I don't mind the local woman's club meetings, because it's genuinely enjoyable to catch up with local gossip over lunch, and I can stand board meetings, because they have an enumerated agenda that requires periodic votes on concrete resolutions. Neither format encourages complaint-fests.

Murph said...

The best meeting-manager that I ever experienced was a business continuity coordinator for a mutual fund firm. She would: distribute a proposed agenda (and ask for additions) before each meeting; start on time; manage the conversations (e.g., follow the agenda; return to the agenda if/when people started getting off topic); take down names of whoever would be responsible for which "action" items & reporting back (and when); review the action items & responsible names as the last item prior to ending the meeting - on time. She would then distribute a post-meeting summary & action item list.
The action items & status reporting on same would form the basis for the next meeting's agenda. All done with a smile and a congenial tone and attitude.

She was awesome, and her meetings were probably the most productive I've ever attended.

Texan99 said...

That just makes my heart flutter. I've worked with a few executives like that. They're such a pleasure. If people don't leave a meeting with a clear idea who's supposed to do what and by when, it's hard to see what the point was. I used to like to keep a chart of pending tasks, deadlines, and personnel assigned. We could change it whenever necessary, but the information was considered good until someone checked in with the group, explained why a change was needed, and got a consensus on the change. It's the only way to keep a complicated, multi-person effort on track. Each person can have all the autonomy he needs within the limits of the task and the deadline.

Assistant Village Idiot said...

Caseload meetings have a natural structure, because we have to cover an identified number of patients in a set period of time. Everyone taking their own notes works for about half the hospital's teams, and almost works for another quarter. This leaves 25% of the teams that need a tighter declared structure. I got advice from a wise psychologist years ago who observed "Your job does not allow you to leave the table until you know definite answers to some questions. Other people can contemplate their navels about the patient all day, you can't. It's okay for you to say that." I learned to. Is Jason going to be ready to go by the end of the week, or are we going to have to apply for an Involuntary? He has appointments with Seacoast next week and his mom needs to know whether she should keep paying his rent. Yet it can be a long hard slog with teams that resist decisions. It can take months to get them working well without whining and sniping all the time.

Texan99 said...

Some people want to talk only about the burden, especially how difficult it is to make some decision or complete some task. Sometimes it's helpful to lay out what the status quo decision is. If we can't make a reasonable guess that Jason can be ready to go by Friday, that means by default we're telling Mom she needs to pay for another week of rent, just to be sure. Everyone OK with that, or do we feel confident enough of a prediction that we can tell her to skip it? No harm in saying we're not confident, we just have to be clear, give Mom some warning.

Similarly, we don't really need the details of how many of your people are out with the flu and when each of them called you and what their symptoms are. If the brief is due Friday, we have a few choices. Other personnel can be brought in to provide emergency backup, or we can ask opposing counsel or the judge for an extension, but one way or another, it requires a decision today. Lots of people would feel completely comfortable just complaining about the flu today, then waiting until the deadline to say, what did you expect? Everyone had the flu. What kind of monster doesn't understand we can't be blamed for the flu?

I often felt that much of my job was to canvass the team frequently with the question, Still OK with that deadline we all agreed to? If not, why not, and what do you propose to do about it? Do you need something from me to fix the problem, or have you got it? It works the same way now with contractors. Some people never really get the knack of predicting how long they'll need to do something, or how to communicate when predictions change. They live in the swirl of the feelings of the moment--and they have no idea why they have to have a boss.

RichardJohnson said...

As a board member of my HOA for 10+ years, I have seen enough meetings. When a new board took over some 10 years ago, after gross negligence on the part of the old board (controlled by a wealth investor who sold his units before the new board took over.), meetings were raucous. This was at least in part in proportion to the problems we faced regarding our lack of funds and the need to pay for needed repairs. At the beginning, our President was not an assertive sort, which didn't help for controlling the meetings. After 6 months, he resigned.

Over the years, meetings got better. We accumulated the funds to pay for needed repairs, which reduced discontent. Homeowners could see the results of their increased HOW payments. One factor in helping meetings was to limit the time a homeowner has to speak. For example, an elderly homeowner tends to ramble. We told her to say it in 2-3 minutes.

HMS Defiant said...

It was a joy to work with professionals and our twice weekly meetings ran like clockwork and left everybody fully informed and up to date on where we stood with regard to current operations, future operations, casualties, logistics, personnel and training and we generally got through those meetings in under 45 minutes and they included TELCONF with overseas leaders. I contrast that with pre-war meetings that would drag on for 4 hours and left everyone in the dark about just about everything. Meetings require organization, an agenda and a willingness to exert dictatorial control by the person leading the meeting.

Texan99 said...

I had a colleague who was sometimes criticized for his scorched-earth bankruptcy litigation style, which was tremendously effective strategically but made enemies in a field that depends a good deal on trust and cooperation extending from one big case to the next. The head of our department was the loveliest fellow imaginable, who could command loyalty and trust from nearly anyone--but he achieved these things at least in part by avoiding conflict, even to the point of having a hatchet-man for a close associate to do the dirty work.

As my colleague put it, "My bankruptcies are finished in a year or 18 months and resolve the issues that made the company fail. [Bob's] last for three years and end in a muddle." "Bob's" career was a lot more successful than either of ours, though. My head knows that the unpleasant things I resented about the hatchet man could with a lot of justice be ascribed to lovely Bob, but if Bob called me ten minutes from now and asked me to fly to Borneo, I'd be filled with a warm glow as I said "yes." He did leave things in a muddle, but it was almost impossible to mind.

To be fair again, the hatchet man was one of the worst offenders I ever knew in running a meeting. HMS is right: a good leader conducts a meeting that leaves everyone better informed about how what's he doing fits into a complicated whole, what is expected of him next, and what he can expect from the others. If he has to be dictatorial to make that happen, he can probably find people to put up with it, because they enjoy the results.