Silos are helpful for storage of things like grain, cement, missiles or anything else that needs to be separated from outside influences (heat, moisture, pests, etc). A silo in a hospital, on the other hand, refers to a dysfunctional mentality that separates staff that work in one department from the influence of others. These symbolic ‘silos’ have no benefit. Their only role is to inhibit the alignment of those that work in a hospital from achieving its overarching goals. The most important and challenging goals – like improving patient satisfaction, safety, quality and even profitability – require systems thinking and wholehearted contributions from everyone for any chance of success. Human instinct focuses one’s work within small teams that think and act homogenously. It is an unnatural act to work with those that think differently. Based on these intrinsic truths, even the most severe case of silo mentality appears normal and would not raise red flags to those in charge. Identifying the silo mentality requires a proactive effort to seek out the signs. Here are the classic indicators that your hospital suffers from silos:
1) Patients: “the care here is so fragmented, the left hand doesn’t know what the right hand is doing” (the ‘right/left hands’ are the departments not working together)
2) CFO “our physicians cause too much waste” (often the CFO has not pinpointed what constitutes waste and explained that view to the responsible physicians directly: evidence of two departments not sharing information)
3) Nurses: “why do we need to use so many workarounds without ever fixing the problem” (workarounds are required to address problems that happen between different departments that lack accountability)
4) Managers: “meetings to solve the problem are great but my staff are too busy to attend” (systems thinking requires getting all stakeholders together in order to share their unique view of ‘the elephant‘)
5) Leaders: “staff don’t understand how their role influences our overall organization”. (the inevitable result of indicators #1-4)
Silos are a fixture in hospitals. There are a variety of reasons this happens, but most important is the insidious cultural incompetence of those in charge. Healthcare is by necessity a complicated mix of technical and managerial expertise that needs close collaboration between a wide array of stakeholders. Collaboration among the different specialties is not the default path. Instead, ingrown habits of technical and managerial experts lead them to focus only on their unique area of expertise. When such habits are left unchecked, a form of tribalism develops that is every bit as fierce as the cultural clashes seen between different religions, races, sexual orientations, political parties, etc. The deeper problem illustrated from this clash is that it is based on widespread unchallenged assumptions. For example, physicians, administrators and other hospital staff often use phrases like “us vs. them” and “not my job”. When they do, they provide clear evidence of the silo mentality (and therefore cultural incompetence), yet these types of comments remain commonplace and seem unremarkable. Imagine how different the reaction would be if the same staff used a racial slur or denigrated the religion of a colleague. Most of us are completely unaware of our silo mentality and how it causes certain data, counterevidence and other points of view to be ignored or discarded.
A excellent recent TED talk by Middleton introduced concepts important to cultural competency that help explain why silos have been so hard to solve. At the same time, her ideas point to the optimal solution for this dilemma. Her model is that each of us have core beliefs that are absolutely crucial to the identities of clinicians and managers. The more they demonstrate how loyal they are to these core beliefs, the more trust they gain from their in-group colleagues. Each group also has beliefs that are flexible, that are based in part on listening and learning from each other. The more they demonstrate this flexibility, the more the two groups gain the trust of each other. There are also what she calls “knots”, which are the unchallenged assumptions that each group has about the other that limit our flexibility. In hospitals, both physicians and administrators feel they need to protect the hospital from each other: administrators “don’t care about safety” and doctors “don’t understand finance”. It is important to understand when these assumptions cause us to miss opportunities. We will unlearn our false knots by engaging in multidisciplinary and cross functional teams to bring forward more innovative solution. The power of diversity on teamwork is well documented. It creates the necessity and collaboration needed to generate change.
