By Lori Chovanak King, DNP, RN, APRN-BC 

Excellent healthcare leaders are just as important as excellent clinicians when it comes patient care. Studies show both have substantial impact on patient outcomes and the organizational bottom line.

The best leaders in healthcare will recognize not only their role in leading operations but also take steps that positively impact patient lives – without needing to ever touch the patient. A critically important step leaders can take for the patients is to promote a culture with low power distance (relationship focused) rather than an authority focused one with high-power distance.

What is power distance?

Simply put, in the work setting it is defined by the actions and behaviors that exist between two individuals where one is in a superior position over the other. This is taught by the Labor Relations Institute as a fundamental concept in becoming an approachable leader. Watch this video for a summary of researcher Geert Hofstede studies on power distance.

Examples of power distance exist throughout healthcare organizations. Front-line clinical staff are in low power positions compared to the high power position of the managers. Managers in turn are in the low power position compared to their directors.

How does the organizational hierarchy outline impact safety, quality, and patient outcomes? It’s not only impacted by a well thought out leadership design but is also deeply seeded in the relationships of those holding each position and those reporting to them.

Here’s a personal story to show the reality.

I was emergently called into the hospital to care for a patient having a cardiac issue. Our on-call team was mid-procedure when I observed something was terribly wrong. Under the sterile blue drape our patient was hemorrhaging onto the floor.

A very quick assessment for the source revealed the bleed was pulsing out from the artery we accessed for the procedure. It was not visible on top of the drape as the bleeding was sneaking around the underside of the patients arm, following the metal frame of the x-ray table and dripping onto the floor up by the patient’s head - a far distance from our procedural site.

Knowing how quickly we needed to act, I announced to the team that we needed to stop the procedure. The doctor who was known for being a “difficult” personality (high power distance, focused on authority) continued on with the procedure stating “I’m almost done. Whatever you need can wait.” Being a fierce patient advocate I was compelled to again announce - albeit this time a bit more firmly - that we needed to “stop now.”

I pointed at the floor so he could visualize the problem and it was then that he became equally alarmed. We stopped. I quickly donned sterile gloves and applied pressure around the procedural sheath to stop the bleed and the doctor was then able to safely finish the procedure.

Afterwards, he apologized for his abruptness and thanked me for being persistent. We discussed that while we were only 10 minutes from finishing the procedure, had we not stopped to find and address the issue, our patient could have easily experienced critical blood loss with grave issues.

We talked about how it happened, inspected the equipment for issues, and discussed how to avoid the same situation for future patients. As we ended the conversation, I reminded him that making himself easier to approach would help newer or younger nurses who may be intimidated by his disposition and may not have been so persistent.

Our roles did not change, but the wide power distance between us was reduced and his disposition softened. Our bold conversation turned into years of friendship and a strong working relationship. In the presence of wide power distance this situation outlines the critical need for narrowing the gap between authority figures and those who answer to them.

Closing the power gap for business operations, and easing transition to value-based care.

In addition to the impact on patient care delivery, reducing power distance can improve business operations by encouraging new ideas, strengthening trust, and opening bold conversations to address issues across the system. This is particularly important considering the transition to value-based care.

Healthcare has been making moves from quantity to quality since 2005 and it is not an easy road. Driven through federal legislation and rulemaking, CMS incentive programs, and payors offering provider contracts with additional reimbursement linked to high quality measures.

This change requires hospitals to adapt and innovate for balancing financial solvency with integration of value-based processes. This requires:

  • intricate tracking of quality (i.e. falls, infection rates, readmissions) while dialing in cost;
  • re-evaluating care delivery with frequent necessary changes to achieve the quality measures impacting reimbursement;
  • partnerships and mergers to leverage resources and broaden services; and
  • a push to achieve high levels of patient satisfaction and employee engagement.

This transition is intricate, expensive, requires levels of risk, and is a shift requiring collaboration among teams. Clearly healthcare leaders have a lot on their plate.

Narrowing the power distance gap.

With so much to do, we need strong teams that value each other. One person alone cannot do it all. This is where healthcare leaders can have a great impact by reducing the power distance gap. It is like a magic wand that can make a profound difference.

Great healthcare leaders understand the powerful impact they have on both business and clinical outcomes of patients.

Get started making it happen.

There is a great deal that can be done to begin to reduce the gap in power distance. The first steps are awareness of the characteristics of their own work relationships - leading by example.

Check out this webinar where you can learn more about the physical, behavioral, and verbal cues that will let you know if the “gap” is wide, plus download a helpful tool that can help you recognize gaps with your own team.

Ask yourself some questions to start. Are your people comfortable approaching you? Who do you avoid and who avoids you, and why? What does their body language and eye contact tell you during interaction? What is your body language? Do your team members share opinions or just ask for yours?

Then start implementing a few changes. Take steps to become approachable. Listen. Be visible. Sit down and limit distractions during interactions. Follow through. And, my favorite - embrace the mental attitude that you will never be too busy to care.

By creating closer more open relationships within your leadership environment, you will be setting the example and expectation that the culture follow suit. Your team will be more cohesive, change will come easier, patients will be safer, and your bottom line will reflect your amazing leadership.