SaferPatients

Measurement. How to measure, what to measure, when to measure, who should measure, where to measure. Despite the “culture of measurement” that exists in most hospitals today, I continue to get these type of questions after almost every presentation I give about implementing aviation-based teamwork and safety tools in healthcare.

Last week I spoke at one of the ten largest hospitals in the country about implementing a Crew Resource Management-based safety program. Sure enough, during the Q and A at the end of my presentation, one of the participants started a string of questions about measurement. This institution is an academic medical center and the measurement questions centered on how to design a data collection plan to support the preparation of a manuscript suitable for peer reviewed publication.

While creating a measurement plan to support articles in peer reviewed journals is important, it is only one of the goals of an effective measurement plan for any cultural-changing healthcare initiative. The best measurement plans also provide a means of documenting the “before” and “after” picture resulting from your team training initiative, and effective measurement plans feed to leadership the data and stories they need to close the loop with physcians and staff. All three of these aims are important and necessary to success.

Collecting data for use in peer reviewed journals is important because this goal brings a level of rigor and science to your measurement. Knowing that your data analysis will eventually withstand peer scrutiny provides the sort of academic scholarship that will help your results resist criticism from the naysayers. I always highly encourage our clients to create their measurement plan with this goal in mind. It helps them aim high and approach the task of data collection and analysis with discipline.

Secondly, an effective measurement plan will allow the institution to see the results, in a quantifiable way, of the effort they have made in the change initiative. With a good plan to guide them they will have the data to say, “This is where we were then, and this is where we are now.”  When I help institutions build their meaurement plan I ask them to envision the same group of stakeholders currently  in the room assembling together again six months from now. In the front of the room sits the CEO or the Chariman of the Board and it is your group’s responsibility to justify to the leadership your effort and investment in the CRM-based training initiative. I ask them, “What slides will you use and what will be on those slides?” So a good measurement plan works backwards from the end. Said another way, “Begin with the end in mind.” See in your mind’s eye the picture you want to paint and then work backwards to determine what data will need to be collected to paint that picture.

Third, great measurement plans work for the folks that actually make the change initiative successful - the physicians and staff at the point of care. Remember that you are asking those providers to do things a different way, to use new skills and tools to help reach your safety and quality goals. That change requires effort. It is just plain hard, persistent work. To keep the folks at the point of care motivated to continue to make that effort requires feedback to them that the effort is worthwhile - that it really makes a difference.

To communicate to them that it makes a difference, you have to be able to show them with facts their effort really is worthwhile. If created well, your measurement plan provides you the data to be able to do this.

My experience has been this third goal of measurement is the one most hospitals struggle with. They do a good job of publishing great results for “outside” consumption, and are really good at keeping leadership informed of the ROI on the effort, but somehow, in the press of the daily grind, forget to feed back to the front lines the results of the effort they are making.

And in terms of sustainable success for your culture changing initiative, this third aim of a good measurement plan may be the most important.

Conversations with low performers are always hard to have. Nobody likes them, everybody dreads them. Consequently, they don’t get done near as often as they should. Unfortunately, no one wins, not even the low performer, when the needed conversation is avoided.

I just finished a leadership training session with two hospitals in South Florida. Both are part of a very good five hospital system in and around Hollywood, Florida. The system is in the process of implementing the LifeWings Patient Safety System in all of their ORs. For several months now, my colleagues and I have been shuttling back and forth to Florida as we conduct leadership training, teamwork training for the physicians and staff, and create and implement Safety Tools like checklists, standard operating procedures and communication scripts.

Our session on Thursday provided the hospital and OR leadership teams the change leadership tools they needed to ensure the implementation was a success. I always stress with these executive teams the 80/20 rule - that is the leadership team will only devote 20% of the total time invested on the project but 80% of the success of the project will be be due to that effort.

One of the issues that always comes up is “What do we do with the folks that just won’t change with the new culture?”

After leading these sorts of culture changing implementations for almost 20 years, my experience has been that, in a well run change initiative, about 3% of the workforce will never change, no matter what you do. Naturally, I have come to call them the “three per centers.”

They make up the bulk of your “low performers.” Regardless of what you call them, you have to have a conversation with them, and in that conversation, clearly indicate the consequences of further low performance, and BE ABSOULUTELY WILLING TO IMPOSE THOSE CONSEQUENCES if performance doesn’t improve.

During our training session, I asked the leadership team if they wanted me to conduct a short session on how to have those conversations. It was at the end of a long day and I truly expected them to say, “No, we already no how to do that.” I was a more than surprised with the almost unanimous exclaim from the group to proceed.

I ended up spending more time on the “why” than I did the “how.” I pointed out that to do nothing was not an option…leaving the 3% undisturbed and in place was like leaving a cancerous tumor untreated. All of their hard work in moving the other 97% to higher levels of performance would slowly be undone as the 3% “anchor” dragged them back down to where they were to begin with.

I left them with this thought, “If you are not willing to have the conversations with the low performers, you might as well save your time and energy and not start on this implementation. If you don’t challenge the 3% and move them up or out, you will end up two years from now being very frustrated that you haven’t permanently changed your culture.”

Later that night when reviewing the workshop with the system CMO, he told me the time they spent discussing the 3% was one of the most useful sessions of the day. I asked him why. He responded, “Because all the middle level managers want the hospital administrators and executive team to have all of those conversations. And they don’t realize we can’t be everywhere at once. If we are to succeed, each one of them has to take responsibility, and have the uncompromising willingness to speak up hold their employees and staff accountable.”

He sounded like a Topgun pilot. I think he, and his hospital system, will continue to excel.

In a recent survey of nurses, physicians, and administrators 96% of respondents say they had witnessed or experienced disruptive behavior from a physician.

In my first post, I wrote about becoming a “Topgun” or being the best of the best. In that post I mentioned the major difference between healthcare and aviation I have seen is the willingness of healthcare organizations (as compared to aviation organizations) to tolerate “selective compliance.”

I can think of few examples of selective compliance that are more egregious than disruptive behavior. No organization will truly be SAFE or provide the highest level of care when it tolerates disruptive behavior. Intimidation, violence, abusive language, and angry or dismissive responses to patient needs or staff requests torpedo safe patient care. Patient safety just cannot flourish in that environment. That sort of behavior also leads to exceptionally strong staff dissatisfaction and high turnover. And when your patients see it, it will affect your HCAHPS surveys.

The problem of disruptive behavior and its effect on quality healthcare is becoming so important the Joint Commission is weighing in on the subject. They have released draft standards on behavioral expectations. The standards will require hospitals to develop and enforce a code of conduct.

Based on my experiences with over 85 healthcare organizations, the Joint Commission effort can’t come too soon. Rarely do I work with an organization where the nurses and staff don’t say something like this, “What about Dr. Jones? (or What about Nurse Smith?) Until I see the administration crack down on his behavior, I won’t believe they are serious about changing the culture around here. We’ve been complaining for years and still the behavior persists.”

I am often asked about the keys to creating and sustaining a “Just Culture” or a “Culture of Safety.” One of those critical, but often overlooked, keys to success is having the courage to confront and change disruptive behavior. Culture change is often as much “caught” as it is “taught.” Meaning that leadership has to demonstrate the strength and willingness to do the right things and model the right behaviors.

If, in the interest of patient safety, leadership expects nurses and staff to use assertive, cross checking communications and be willing to speak up at the right time with the right words, then leadership must display the willingness to do the same. Nowhere is this more important than dealing with disruptive behavior. The patient’s welfare demands nothing less.

I am traveling today on an airline. It will come as no surprise to you that I am writing this while sitting in the gate area - waiting to board.With a little time on my hands, my thoughts drifted to the hundreds of times this exact scene has repeated itself in my life. I wonder how many minutes of what could have been productive time has been wasted, waiting to board, waiting to taxi, waiting to take off, waiting for a gate upon arrival, waiting for baggage.It occurs to me that in addition to the financial cost of the ticket, the cost of our time should also be calculated in determining the true cost of airline travel.

Time is also the currency when calculating the “cost” of our experience with the healthcare system. To be honest, when I am not feeling well, I often factor in the time I expect to have to wait to be seen in the decision to go see my primary care physician. Delays of up two hours past my appointment time are not uncommon. The result? I have to be pretty darn sick to go see him - so sick in fact that the time lost waiting almost doesn’t matter anymore. (Which is the same with airline travel - I have to be there so the time waiting almost doesn’t matter any more.)

When really sick, I sometimes even resort to going to the local Minor Medical facility. I have discovered I can often be seen more quickly there without an appointment than I can at my primary care physician’s office with an appointment. So for those with insurance, and thus reimbursed medical costs, the currency we use to “pay” for our healthcare is our time.

Which is one of the reasons I enjoy my work with healthcare so much. In showing healthcare organizations how they can make their processes more safe, we also show them how making processes safer makes them more efficient. One of the really nice by-products of a process that has been rengineered to make it safer is that it often turns out having fewer steps, fewer handoffs, more clarity on who does what, and is therefore, more efficient.

It brings a lot of satisfaction to see a client’s face light up when they analyze their data a few months into the project and realize they “bought” safety and got efficiency in the bargain.

And when the data begins to roll in showing decreased OR turnaround times, increased on-time procedure starts, and fewer unexpected delays, the organization has a very useful tool for its effort to convince physicians to become true partners in the organization’s effort to increase safety and quality. In effect, the “deal” becomes, “You help us get to where we want to be in terms of safety and quality and the benefit to you will be greater efficiency, fewer delays, and less friction with our systems.” This is a deal where everyone wins - the adminstration, the physicians and staff, and most importantly, the patient.

Oops, they’re boarding now - gotta go. My last thought is this - Time is the currency of passengers, patients, and physicians. Whoever can give more of it to any of the three will succeed.

Not long ago I gave a presentation to group of Cardiovascular surgeons assembled for their annual conference. The topic was “How to be a Topgun.”

The group sponsoring the presentation thought I was qualified to answer that question because of my extensive patient safety work in healthcare and my experience (long ago and in a galaxy far away) as a Topgun instructor pilot for the U.S. Navy. (Yes, the same school for fighter pilots that Paramount Pictures featured in a movie of the same name, starring Tom Cruise.)

After the presentation, I answered questions. One of the last questions was one of the most thoughtful. The surgeon asked, “Steve, you have served in regular Navy squadrons and a Topgun squadron. What’s the difference? And my follow up question is this…What is the major difference you see when comparing a Topgun squadron to the average surgical services department of any hospital?”

I paused for a long time before answering. I was worried my response would offend many in the audience. Finally, I confessed my reluctance to answer, offered an apology in advance, and plunged in with the truth.

First, the difference between a regular Navy flying squadron and Topgun is that at Topgun there existed an uncompromising willingness on the part of every Topgun instructor to speak up and demand top performance from his peers. Work-arounds, shoddy effort, selective compliance with standards and protocols, and anything less than your best was just not tolerated. You could bet one of your peers would confront you and demand, in a polite but professional manner, that you clean up your act. Consequently, we operated at a high level and in a way as to not let our colleagues down.

Secondly, (and here was where I was afraid of offending my audience) the difference between Topgun and the average surgical services unit in the average hospital is the rather shocking willingness of administration and peers (of both physicians and staff) to tolerate substandard or disruptive behavior.

Lest you think I am being overly harsh or critical, my comments come from seven years of helping over 85 healthcare institutions implement best practices from aviation. In all that time, I have rarely worked with an organization that didn’t raise the issue on their own. “What are we going to do with Dr. Smith? No one in this organization will ever believe we are serious about changing our culture unless we do something about him.”

I went on to tell the audience that after years of working in healthcare, I had come to believe a hospital had no chance of creating and sustaining a true “Topgun culture” unless they were first willing to set a standard of behavior and accountability, adhere to that standard, and quickly impose consequences for failing to live up to that standard.

Expecting a sullen silence, I was more than surprised to get the loudest and most spontaneous ovation of the night in response to my answer. Clearly I had illuminated the “elephant in the room” and touched a nerve.

Later that night, as I drifted off to sleep, it dawned on me their response shouldn’t have been so surprising. After all, these were surgeons who, despite all of the other options during their annual conference, had elected to spend one of their evenings listening to a presentation on how to be a Topgun. Obviously they had motivation to seek out ways to be the best they could be. In their response to my answer to the questions, they demonstrated they wanted what any high performer wants - to work with and for those who also want the same levels of high performance.

I can’t blame them for wanting that. Topgun was in many respects one of the highlights of my professional career. And I have spent my life since then trying to duplicate that same level of uncompromising willingness to hold one another accountable to high standards of performance. It is truly the secret of creating a “Topgun” organization.