Bridging Silos in Healthcare

Workplace silos are a natural byproduct of professionalism.

Nursing, imaging and the laboratory work independently and collaborate as needed to care for patients.

But silos are often an impediment to improving quality and fixing day-to-day problems.

Solo Silos

A “silo mentality” arises when departments do not want to share information or knowledge within the same organization.1

The term is a metaphor for agricultural grain silos that separate types of grain. A siloed organization similarly separates types of thinking to prevent groups working together.

This kind of culture breeds isolationism, redundancy, “us vs. them” outlooks and poor decisions.

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When a laboratory test is not collected on a patient ward, for example, silos approach the error differently.

Nursing culture writes up the incident from root cause to solution without asking the laboratory, blaming the event on phlebotomist inattention or the tech on call.

Laboratory culture writes its own version of events, blaming the event on an order not being verified, the person on call not being notified, etc.

Both silos are frustrated by an unresolved process that ensures the error will recur, and yet neither bridges the gap to collaborate on a real solution.

Higher stakes often strengthen the silo walls as those within a department become defensive or fear retribution.

Giving a unit of blood to the wrong patient, for example, can quickly generate a trail of blame that prevents departments from working together.

Similarly, nursing medication errors linked to trough therapeutic drug levels can lock down a department culture into a frenzy of documentation that protects individuals and doesn’t consider the big picture of preventing a recurrence.

Up & Over

If your organization chart looks like an upside down tree with the CEO at the top branching to senior leaders on down, silos already exist by design.

As Bloomberg Businessweek points out, “Command-and-control-oriented cultures breed silos. In such cultures, fear prevails. Managers focus on guarding turf rather than on engaging colleagues outside their group [and] if it seems necessary to involve another department or function, a team member runs the idea up the flagpole within his or her silo.”2 This vertical “up and over” strategy is at least once removed from those performing the work.

In your facility’s laboratory, for example, a suggested change in call hours will first be forwarded to a senior leader, who will review at a resource committee, discuss formally with a nursing director who relays this to other nurse managers.

Staff nurses are informed of the change without context, leading to frustration and suspicion.

Worse, a different decision is made and laboratory call hours changed by another department, reversing the process.

Command and control organizations distribute information between silos on an arbitrary need to know basis. Thus, individual decisions are based on incomplete knowledge and are often redundant or work at cross purposes for the patient.

Questions to help determine if your organization works in silos as suggested by leadership expert John Kotter in Forbes magazine are listed in the Table.3 See how many you agree with to get a sense of your culture.

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Systems Thinking

Silos are caused by vertical, fear-based thinking. The opposite of silo thinking is systems thinking, which considers how interconnections affect the complex dynamics of an event in a lateral fashion. By contrast, silo thinking is simplistic and linear.4

Changing from linear to lateral thinking isn’t easy, but there are practical, low-cost steps that a manager can take starting today, as suggested by one consultant:5

  • Reward collaboration. Changing a rewards system to recognize efforts to work with other departments will change a culture.
  • Focus on innovation. Innovative solutions often can only happen when the right people with the right information get together to solve problems. Enabling this kind of interaction and telling these stories will focus energy away from linear thinking.
  • Communicate transparently. Since silos hide information from each other, breaking them involves sharing all information about how the organization functions.
  • Focus on the customer. Silos typically focus on internal issues. Sharing market surveys, feedback, and asking patients and their families directly what they would like to see can turn your team away from a defensive self-obsession.

Ultimately, the patient or customer who experiences poor care or service is the loser in a turf war between silos.

Improve Quality

One approach to bridging silos that can work is laboratory rounding through patient and ED areas to review charts, answer questions, follow up on issues, and speak directly to caregivers.

A few minutes each morning can catch providers to clarify orders and share microbiological culture information. During this rounding, laboratory professionals can review chart history, orders, and anything else about the patient that improves the quality of results.

This access can improve quality. Pre-printed orders can be reviewed for accuracy and clarity, and during rounding the lab team can ask clerical staff specific questions. If a culture needs to be recollected, the team can speak directly to the patient nurse and explain why the original specimen was rejected as well as relay the proper collection technique.

Being a visible, approachable resource bridges silos and fosters different thinking about how problems can be solved.

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At Penobscot Valley Hospital in Lincoln, Maine, we do just that.

Each morning two laboratory team members round at nurse stations, focusing on pending cultures, recent or pending obstetrics patients, and blood transfusions. Problems can be solved without a committee.

For example, during one morning visit a ward secretary suggested that instead of the laboratory calling her about a critical value and she pages the nurse to call the laboratory, why not page the nurse directly? These and other problems are easily solved without silo thinking, improving quality and creating an expectation of collaboration.

Silos thinking is optional.

By understanding its roots and how to bypass vertical, silo-based communication you can reach across departments and work directly with nurses for better patient care.

Scott Warner is lab manager at Penobscot Valley Hospital, Lincoln, Maine.

References for this article can be accessed here.

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