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Do hospitals need more outsiders?

April 2011

If you look at the Washington Post’s “On Leadership” series, you will see the word “outsider” in the title of several articles.

One article approves of recent personnel changes in the White House, stating, “A bigger mix of inside and outside candidates … could go a long way toward balancing frank assessments and bold new ideas with institutional knowledge and trust.”

Another article points to the recent appointment of former publishing industry executive Cathleen Black as chancellor of New York City’s public school system. That one argues that “a good manager can lead in any environment and an outside voice can work wonders to enact change.” This last article highlights two characteristics of successful leaders: being a good listener and a strong consensus builder, traits that can easily transfer from one industry to another. (Ms. Black’s tenure ended today … a clear sign of the risks to the outsider!)

An outsider by definition is someone who poses a challenge. He or she arrives with a whole different set of experiences, ideas and a vision that may upset the status quo. What an outsider brings is what we sometimes lose in the daily grind of work habits and routines: a fresh perspective.

Outsiders also face great difficulties and can make a lot of mistakes. If outsiders just start pushing new ideas–without first assessing the current state of affairs or focusing only on what doesn’t work without recognizing what does–they can quickly become marginalized or lose credibility.

This happened to me in a former job when I was quick to point out how stupid I thought a process was, without understanding the reason why things were done that way and why they could not change. In this case, a long-standing policy regarding administration of benzodiazepines on the pediatric unit clashed with more recent advances in pediatric moderate sedation for painful procedures and with the experience of newer pediatric hospitalists in the area of sedation. There were reasons for this policy, but I just attacked it as “unreasonable.” The result? The policy is still in place.

But I’ve always felt that “could” and “not” are two words that should not be uttered together in a sentence.

The fact is that hospitals, like any big organization, are adverse to change. Why? Because change involves risk, and someone has to take responsibility for the risk inherent in change. And no one wants to be responsible if the proposed change does not produce the intended results.

But an outsider has an advantage: He or she has nothing to lose. They come in fresh, with no constituencies to satisfy, no history to scrub, no relationships to sever. An outsider revels in being a rebel, and being a rebel implies constant change. The constancy of change engenders fearlessness to risk. The outsider knows that change is the coin of his realm, and that there is more risk in the sclerosis of unmovable goals.

So what is an outsider to do who wants to push for change? First, listen, look and learn. Examine the processes you manage or supervise and try to understand their origins. Sometimes, policies spring from myth, whether it is that newborns do not require pain control for their circumcision or that practicing defensive medicine will protect you from being sued. Try not to criticize a well-worn process as useless or irrelevant. Medicine, like technology, changes constantly, and the new approaches that you’re now championing may end up being the outdated ideas a future outsider will find shockingly inadequate.

Second, find allies. The success of any organizational change depends on support from people already there, who have fresh ideas blossoming in their minds. Listen to the history of previous changes; and learn the backdoor conversations that stymie growth, the griping in the midlevel administrative offices, those cubicles in which people worry that change equals joblessness. Learn from other people’s mistakes.

Third, stay fresh and humble. An institution can quickly swallow you whole, anoint you with titles and benefits to make you the new status quo, giving you enough incentives to fear change. To be an outsider is to be a revolutionary without triggering wars, stimulating change without being confrontational–and without being overwhelmed by the sheer inertia of an institution.

To be an outsider within an organization can be both a blessing and a curse, but crusaders for change need not be quixotic lunatics. All you need is a good set of ears, the ability to forge alliances based on trust and respect, and the humility to accept that change is inevitable, even when what’s changing are your own fought-for ideas. Being an outsider within an organization can be painful, even marginalizing. But being an insider can sometimes be worse.