The Director of Surgical Services Around the World
Despite the bureaucratic and cultural differences in foreign countries, the challenges of improving health outcomes in surgical services, while also reducing costs, are the same. In addition, resistance to organizational change, personality clashes, and maintaining staff morale are all universal issues.
However, the methods for successfully navigating those choppy political waters can differ between countries (just like states, here in the U.S.). Knowing in what ways to manage that is a talent in and of itself. Three perioperative leaders share their experiences managing healthcare delivery internationally.
Laurie Watts: Director of Endoscopy at a Saudi Arabia medical center
Mississippi native Laurie Watts began her career as a travel nurse in 2001. She took a 13-week assignment in California that she says “turned into 17 years” as she fell in love with the Bay Area and didn’t want to leave. She was soon offered a full-time position as a staff nurse at a brand-new endoscopy center in 2003. Quickly earning promotions, she became Director four years later. But she was always intrigued with international nursing because she had a reverent curiosity about other cultures, particularly Middle Eastern culture, and was always up for a professional challenge. After exploring a handful of opportunities that didn’t pan out, in 2017 she accepted a position as Director of Endoscopy at a hospital in Saudi Arabia. After four years she is moving back to the States for a new gig but would do it again without question.
“I’d applied to this hospital twice, but at the time they didn’t have anything for me. I had interviews at other facilities there and it just never felt quite right,” Watts says. “I began to think maybe I’m just not meant to go. Then in 2016 I got an email from the place I applied to twice, saying that they finally had a position available and wanted to interview me.”
Watts had a bumpy start to her tenure as director. Even though she was sought out and hired for the position by executives, the practical reality on the ground was that a unit full of male physicians did not fully embrace a Western woman pointing out issues and asserting what needed to be changed.
“For the most part, my suggestions were ignored initially,” Watts says. “To be fair, there is not nearly as much autonomy as we have in the States, regardless of gender. And the dynamic between doctors and nurses where doctors are frequently condescending? That exists in the States, but in my experience here, it’s tenfold.”
Very quickly, Watts realized she had to figure out how to make inroads without alienating colleagues. She decided to stand by her professional opinion and detail what would happen if changes weren’t made. Then, step back.
“Within less than a year, some of my predictions began happening, but it wasn’t quite enough to get their attention. Then things began to snowball and got so serious that we had to shut down the unit and renovate the entire thing,” Watts says. “In my initial assessment, that is exactly what I’d proposed: unit renovation, procurement of state-of-the-art equipment, implementation of best practices, education of staff to align with best practices. I won’t take all the credit because it was a team effort, but I’m leaving the unit in better shape than I found it.”
Although there were challenges initially, once trust and transparency were established, those once tense working relationships later blossomed into extremely healthy ones. In some cases, friendships evolved. These relationships, forged thru conflict, resulted in some of her most cherished memories in Saudi Arabia and added to the difficult decision to return to the States.
“This was an amazing journey, and even looking back on my most challenging days, I would do it again without a second’s hesitation,” Watts says. “Saudis are extremely hospitable and so immensely proud of their heritage. I will forever remember this life-changing experience with fondness and gratitude.”
Soheila Ahangarzadeh: Director of Surgical Services at Mongolia University Hospital
Soheila Ahangarzadeh spent a spring semester as a student nurse and the experience almost turned her off to nursing. Partnered with a charge nurse, they had 14 patients under their care (two comatose they had to turn every two hours) with limited support from orderlies and LPNs. The workload brought daily exhaustion, both physically and emotionally. The holistic education she received in nursing school was contrasted by the standards practiced on the job. She began to reconsider her choice of career.
“I felt like I might have wasted four years of my life because this was not the standard of care I wanted to provide for my patients,” Ahangarzadeh says. “There was no quality time with each patient, getting them involved in their own care, physical, psychosocial, and spiritual. Those were the things we learned in school. In real life, I felt it was impossible to deliver that kind of care.”
But then she took a surgery elective in the summer the spring and her last semester, and immediately found her niche.
“I loved it. It was one-on-one and felt amazing. I’ve been a nurse in perioperative services ever since,” Ahangarzadeh says.
Ahangarzadeh spent most of her career at trauma centers and large hospitals with a dozen or more ORs as a unit leader, head nurse, and eventually upper management. As the director, she helped expand the Texas Health Harris Methodist Hospital Southwest in Fort Worth, TX. This facility functioned mostly as an ASC because about 85% of patients were outpatient. There, she had an administrative director that trusted her to do what she felt was best for the patient and the hospital. Texas Health Harris was the first to successfully outsource laparoscopic instruments and used a supply usage technology that removed nurses from the administrative part of charging patients for items so they could focus on patient care more.
Another highlight of her career was opening a brand-new operating room at a children’s hospital in Orange, CA, and preparing them for state licensure. To receive their licensure, they had to demonstrate that every single person on staff had been trained to use every single piece of equipment typically used in operating rooms.
In 2014 she was recruited to open a hospital in Ulaanbaatar, Mongolia, and prepare the facility for Joint Commission International. She focused on education, training (including mentoring for senior staff), policies, and perfecting the art of communication. While the disparity between nurses and doctors exists everywhere, Ahangarzadeh says it was more visible in Mongolia. Nurses and junior doctors would often follow doctor orders on patient care uncritically because they didn’t want to appear to be challenging the doctor. And they had reason to be cautious; simply asking questions could be met with blame-shifting and a stern scolding.
“No matter where it’s done, that is very rude behavior,” Ahangarzadeh says. “One of the things I emphasized was critical thinking. We had to make it clear that asking a question is not an insult, it just means that person is trying to understand the intent and do right by the patient.”
Even though the staff was used to how they had practiced previously, they were extremely open-minded and ready to learn when it became clear that Ahangarzadeh’s methods worked.
“There was none of that ‘I already know this.’ They were very skilled and experienced, very seasoned nurses and doctors, yet they were eager and to learn and very humble,” Ahangarzadeh says.
Today, the ex-pats are gone, and the hospital is fully run by a CMO, CEO, and CNO (Ahangarzadeh’s successor) who are local.
In June of 2019, Ahangarzadeh was invited by the Ministry of Health as part of an international consulting team to return to Mongolia. The project involves designing the infrastructure and all aspects of nursing in a district hospital. The project is still ongoing; completion was delayed due to the COVID 19 pandemic.
Margaret Hartman: OR Business Manager at Cleveland Clinic, Abu Dhabi
Margaret Hartman began her career in her home state of Ohio at the Cleveland Clinic in 2003 as a scrub and circulating nurse in the cardiothoracic ORs. She was nurse manager for several years before getting the opportunity of a lifetime in 2014 – she was among a select group of staff sent to Abu Dhabi to open Cleveland Clinic’s first medical center to offer surgical services outside of the U.S (there is one physician clinic in Canada). Her role would be OR business manager.
“It was great because I had formed relationships with people in the decade I had been there,” Hartman says. “I knew the surgeons and co-workers that were going over with me quite well. That context was also a sort of safety net for me because it was my first time over the Atlantic. I had never even been to Europe at that point.”
One logistical obstacle that is uncommon in the U.S. is having a “middleman” when buying equipment and supplies. Being unable to communicate directly with a vendor, who was typically in a different country, meant leaning heavily on strategic planning to have what they needed delivered on time.
Another interesting hiccup was that even though everyone spoke English, there was still a mild language barrier.
“We quickly realized that not everyone called something the same thing,” Hartman says. “We had meetings where we had to agree to call this a ‘trolley’ and this a ‘pencil.’ It was a challenge I hadn’t expected, but it was actually fun to work through that.”
On the healthcare delivery side, the American team had to learn how to be respectful of cultural customs when communicating with female patients of childbearing age who were not married. If pregnancy status needed to be verified there had to be workarounds for how and in what manner to obtain a test.
When the hospital was first opened, the country did not recognize brain death. This only allowed living or personal donors for organ transplants.
“It took a long time to get the right people to influence and change the law on that,” Hartman says. “But by the time I left, they agreed to recognize brain death and we were able to expand our transplant program.”
Hartman appreciated the way technology was seamlessly intertwined with daily life (she believes it may be impossible to function there without a smartphone), the commitment to family, and the welcoming of religions other than Islam.
“There was a Catholic church and a non-denomination Christian church that everyone was welcome to go to,” Hartman says. “The whole concept of Ramadan is amazing; the fasting for that long and then coming together as a family unit for their Iftars—when the fast is broken at sunset—and welcoming us to attend those. I don’t think any of us will forget those Friday brunches. I had the opportunity to meet some wonderful people and we’re still good friends today. It was all just an amazing experience.”
By Carisa Brewster and Greg Masson