Improving patient care with the structural tension model

As a healthcare administrator with more than 30 years of experience, I have been exposed to numerous management philosophies, approaches and models. Some have disappeared or faded but the structural tension model (STM)¹ continues to serve me — and my healthcare organization — well. STM combines creativity with structure, prompting team members to engage with each other differently and tap their creativity to address root problems, design solutions and implement them.

The model was introduced in the early 1980s by Robert Fritz, author and management consultant, who is called the founder of structural dynamics.² STM helps leaders create a vision and gain full engagement and commitment from staff while moving the team forward. In our group, Marymount Hospital, Garfield Heights, Ohio, the model has helped to solve problems while creating an environment of optimism, confidence and resilience among colleagues, peers and team members.

Too often a solution is mandated and staff are expected to comply with little consensus or explanation of how a solution was created. For example, practices must align with many federal requirements — PQRS, VBPN, meaningful use and HIPAA compliance. And we, as leaders, tell our staff to comply with these requirements with little time for explanation or reasoning. Mandates create resentment, fear and inconsistent outcomes because there is often a lack of ownership. As a result, the model of command and control becomes ineffective and leads to poor results. When I learned about STM several years ago, it made sense to me because it:

• Provides a focus for solving problems
• Takes people out of the typical drama and conflict that plague problems
• Allows team members to be heard and to identify issues
• Helps everyone find common ground toward a solution
• Identifies strengths, barriers, gaps and solutions as well as ways to pursue a common vision

Practical uses

The STM framework searches for the most effective way to provide quality patient care by concentrating on the end result or goal to which the team has agreed. The model takes the emotion or ego out of solving a problem by guiding team members away from the drama (what I call “white noise”) that distracts them from developing core strategies to solve problems. Instead the focus is on an overall commitment to achieve great purpose by raising the bar in terms of outcomes, quality, service and caregiver/patient experience. The model’s key steps (as shown in the case study below and Figure 1) are to:

• Focus on our vision
• Define our current reality
• Leverage our strengths toward action
• Blaze the trail for closing the gaps
• Clear the obstacles that get in the way of solutions
• Create action steps to achieve problem resolution

To create a common purpose and vision, team members must develop solutions together instead of relying on leaders to develop solutions independently. Instead of focusing initially on solving a problem, STM helps the team define what the issue would look like in a perfect world. That leads to creating a vision and common goal, and keeps team members grounded in the solution. Once the goal is determined, the team begins a dialogue about the current reality — where they are now. Members identify the department’s and organization’s assets, including people, resources and technology. Armed with a vision and an understanding of the current reality and strengths, team members look at how they can close the gap between the vision and current reality so they can solve the problem.

The model requires each team member to be heard without judgment as well as to actively listen to other team members’ perspectives and concerns without interruption or commentary. In her book Time to Think, Nancy Kline explains the concepts of attention, ease, appreciation and equality. Attention is given to the person who is speaking, and each team member’s contribution is appreciated. If a group is not allowed to provide feedback, people feel like victims to the solution. By co-creating a solution, team members not only feel heard, respected and valued, they are encouraged to think for themselves, which moves thinking further.

Our group used STM when the practice was cited for not complying with various regulatory agency requirements and standards. In the old model of problem-solving, we would have used a command and control approach to fix the problem in one to two weeks with little buy-in or understanding from the staff. But leadership’s solution wouldn’t result in lasting change because the staff had a limited understanding of the reasons behind the solution. With STM, we called on a diverse team of caregivers with various perspectives to develop the solution. Following the model’s guidelines, the team began by creating a vision of the solution, identifying the current reality and practice strengths, and recommending next steps, as summarized in the case study.

STM allows leaders to effectively co-create a team approach in solving problems and coach others how to achieve results. STM advocates for making a difference with current resources and drawing from staff energy to achieve desired outcomes.

Case study

Problem: We have been cited for noncompliance with various life safety issues.
Vision for the issue: All caregivers understand the importance of being in compliance with life safety regulations because we are committed to a safe environment for our patients and employees, and because it is the right thing to do.

Current reality: We continue to be noncompliant with consistently achieving and following life safety regulations. For example, we place too many oxygen tanks in one area and store items too close to fire sprinklers.

Strengths and assets that can support action: Senior leadership is committed to lead change. Employees are open to new ways of doing things if they have time to implement change. Emails, newsletters, staff meetings and management meetings are available for communications.

Barriers and roadblocks toward action: Solutions are made with little understanding of the “why and how” by staff. Communication channels are insufficient; one email isn’t enough. In the past, solutions have resulted in inconsistent results since there is little understanding of why we are performing tasks. Outcomes are not sustainable because we are doing too many post-audits to ensure compliance. Leadership is correcting problems instead of all staff working together to solve a problem. Employees follow mandates with little understanding of what they are doing and why. Once staff members are oriented and trained, they are not held accountable for ensuring consistent practice.

Next steps:

• Explain why staff members need to be compliant with the life safety requirements.
• Explain various ways that staff can be compliant with these requirements.
• Appoint departmental safety representatives to advocate for a safer environment.
• Periodically audit various areas of the department. Acknowledge hard work and accomplishments, and explain why compliance is not achieved.
• Communicate to staff via email, staff meetings and other venues.
• Assign pairs of department managers to rotate and review life safety requirements in a different department, and report findings to that department manager. This effort reinforces a team effort and helps everyone understand the requirements.

The result: After developing this plan, we saw increased compliance in following life safety requirements and continued commitment to the process. STM took the drama out of the problem, focused on the solution and gained a commitment versus a compliance approach.