Hospital Politics Don’t Have to Be a Dirty Business

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Dear Director: I’ve never liked hospital politics, but now that I’m a Chair, I realize I have to better understand them. How can I wade in without getting dragged down?

Office politics can have a dirty connotation. We know that some people use politicking in a destructive way to get ahead in an organization. But we have to accept that every organization (including a hospital) is a political entity. There are different views within any organization about how things should be handled and generally a limited budget. I work “inside the beltway” in D.C., so maybe politics is integral to our landscape, but as ED leaders, we interact with virtually every other department in the hospital, so it’s critical we learn the skills necessary to build bridges with others to help achieve our goals.

So that we’re on the same page, let’s think of the definition of office politics this way: using your social network and power to affect positive change within an organization. In one of my suggested summer reads from earlier this year, the HBR Guide to Office Politics by Karen Dillon, the author points out that it’s important to be “constructively political” by understanding your colleagues and working together towards a common goal. It’s critical to think about office politics and have a strategy for navigating it. Ultimately, it’s about working productively with your colleagues—even the challenging ones—for the good of your patients, your organization, and your career.

Good Political Behavior—The Basics
There are both positive and negative behaviors we can exhibit that work to influence others. You can almost never go wrong when you put the patient first. While it sounds easy and obvious, it can be a tough rule to live by. Getting the critically ill patient to the ICU quickly benefits the patient and our metrics, but sometimes getting the extra test the hospitalist wants (that might enable a soft admit to go home) benefits the patient but not us. These are fairly typical discussions held with leaders outside of the ED, and much of our influence upon each other will be based on existing relationships and whether there is already a mutual professional respect between the people in the discussion. In many ways, it comes down to having the right attitude about work and your responsibility.

If you’re in a meeting with someone you’re trying to impress, there are also obvious behaviors to demonstrate. Preparation can be critical to having a positive image. Read material ahead of time, if appropriate. Spend time thinking about issues that will be discussed and be sure to know the details of a case that might come up. Going to a stroke or STEMI meeting without knowing the details of any fallout cases is likely to result in you looking bad, which effectively decreases your influence down the road. It may be a non-clinical day for you, but if you have a hospital committee meeting, dress appropriately. We’ve worked too hard to get rid of the unprofessional, cowboy ED stereotype. Show up on time (early) to get the lay of the land. Be engaged in the meeting even when the topic is outside of the ED, offer input as necessary, and put your phone away! Plan on staying late. Often, the time after the meeting is key for following up on other topics or taking the opportunity to touch base with another key leader.

Success at Work
According to a study by Lynda.com, there are four key attributes beyond ability that can help determine your success at work: likability, achievements, connections/friends at work, and political skills. While your baseline ability is critical, you’ll notice that the higher you go in the hierarchy, the more everyone tends to be bright. Political skills involve your ability to make new connections, understand coalitions, and use political information when making decisions. This is by far the most misunderstood and neglected of all the success factors.

Next up is past achievements, such as projects you’ve worked on. Frequently achievement gives you momentum for additional opportunities and success. Work is not a meritocracy, and factors other than your professional performance contribute to your success, with being likable as one of the biggest. I’ve worked with ED docs who wanted to be Chairs but never quite made it because they just weren’t likable. Since opportunity and promotion are not always based on merit, you can bet that friends look out for friends. Hence the saying, “It’s not what you know, It’s who you know.” This is especially true when considering committee appointments. Typically the medical staff president not only appoints the committee chair, but has total control over who sits on a committee. For key committees that involve risk and M and M, it’s obviously critical to have an emergency physician at the table. This is much more likely to happen when one is “friendly” with the person making the appointments.

One of the tools that help directors become successful is having regular meetings with hospital leaders. This builds your relationship, helps with a regular exchange of information, and if done right, let’s them see your skills in preparation, analysis, and strategy. Have an agenda, bring key figures, and discuss next steps to keep your department moving forward.

Handling the Difficult Situation
As a young administrator, I stuck my foot in my mouth more than a handful of times. Sometimes I had to apologize. Sometimes I had to do some recovery and offer further explanation. What I learned is that I need to think before I speak, and writing down key points works better for me than speaking off the cuff and thinking I’m going to make a cohesive argument. I should avoid making jokes at other’s expenses (long story), too.

With that said, we’re going to find ourselves in meetings where we face difficult questions. It’s necessary to know your game rules and have some “go to” phrases that buy you time or can stop a situation from boiling over. Consider the following:

  1. Don’t lie, over-commit or become defensive
  2. Acknowledge that you hear who’s speaking, are taking what they say seriously, and will follow up. Try, “This is the first I have heard of this issue, and it is obviously very complicated. I need to get more information, talk to the people involved, and will take the necessary steps to prevent it (or at least minimize it) from happening again, then follow up with you.” Follow-up is actually the key part so that they trust and believe you next time.
  3. If a matter needs follow-up sooner than the next meeting, say you will follow up with the Chair or the person who raised it in a specified time period. This brings them in on the solution and affirms the solution will have their support.

Emails: Take Care
Many physicians run into trouble when sending email. The “Reply All” feature will get you in trouble at some point. Many years ago, I sent out an email to my group about procedural sedation, and I cc’d the anesthesia chair. One of the docs replied to all and insulted the anesthesiologists without realizing their Chair was on the email. That didn’t help our relationship, as we were trying to get propofol credentials.  Therefore, check and confirm you know exactly who is on the Reply All list (Do you know them all? Will they think your response is funny? Is it relevant to all of them? What happens if your email is forwarded?) Save your reply all for when everyone on the email needs to know you’ve received it and are addressing it; when the response has important information relevant to everyone; and when you wish to show support for a difficult issue (in response to your Chair’s email).

Keep in mind that email is not the place for debating issues of any significance (schedule a meeting, or better yet, pick up the phone). Most emails require a direct response from you. If nothing else, the sender needs to know that you received the email and you’re working on the situation, answer or problem. Lastly, don’t only send emails that are complaints or negative. You certainly don’t want people to cringe every time they see an email with your name on it. It really is okay—and highly—encouraged to send a positive email to the lead hospitalist or Chair of Medicine as well (and better yet, CC their superiors).

Hallways and Elevators
We often don’t have traditional offices, and therefore we need to consider other environments as critical for meeting opportunities and engaging in office politics. Hallway encounters are the perfect example, and these should be part of your rounding strategy. When you haven’t talked to the CEO in a couple weeks, you can’t afford to blow off his hallway question of “How are things going?” Your answer needs to instill confidence, but if you have something burning, gauge the appropriateness of the moment to bring it up. If there is something critical, try: “There is an issue with  [problem]but I am working with [name(s)] to get it worked out. I don’t need your help yet, but if I can’t get it worked out, I might need to come to you.” Failing to respect the chain of command in the hospital is one of the fastest ways to make enemies. This answer lets the CEO off the hook for primary responsibility, and it reinforces their confidence in you that you can solve problems.

My wife likes to remind me to always take the high road in difficult situations. Your actions will always be judged in the aftermath, but it’s hard to look bad when you’re on the high road. There will be times when someone is taking the low road or trying to undermine you. You should address these individuals but initially do so privately, quietly, and personally. Try to avoid the common tendency to assume they have malicious intentions, get angry about it, and go talk to the boss.  When you do confront someone, start by talking to him or her directly.  Make sure it’s not all a big misunderstanding. If it is a misunderstanding and you are the one that escalated it, they are rightly going to hold it against you. Have the courage to confront them privately and in person, “I saw what you did. I did not like that. Why did you do that?” But you need to remain respectful and professional. If there is a factual dispute, then it is OK to address it promptly then and there. While it is sometimes necessary and you shouldn’t fear doing so, your goal as an employee is not to have to escalate something to your boss. You want your boss to see you as a problem solver who can navigate complex relationships and still get your work done in a good manner.

Conclusions
Relationship building is not typically taught to physicians, but it is critical for helping to achieve success with your agenda as a director. We may feel like we practice in a silo but for the good of the patient and the good of the organization, we need to develop good habits for interacting with others who have power within the hospital.   

ABOUT THE AUTHORS

EXECUTIVE EDITOR
Dr. Silverman is a partner at Emergency Medicine Associates and is chairman of emergency medicine at the Virgina Hospital Center. He authors the Director's Corner each month in EPM. Dr. Silverman’s practical wisdom is now available in an easy-to-use reference guide. Order today on Amazon.

Dr. White is currently president of the Maryland Chapter of ACEP and has been a medical staff president at two different hospitals. He is a partner and regional medical director for Emergency Medicine Associates.

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