SaferPatients

You can’t get to 100% on your core measures.

The usual mantra is to ‘try harder’. Trying harder is impossible when you’re already trying as hard as you can.

But you can always try different.

In addition to my work for LifeWings I also fly an MD-11 for FedEx. We guarantee your package will be there overnight. On time. A 99.99% success rate won’t cut it. If we deliver 7 million packages a day, that means 700 will not make it on time to the right place and right person. These 700 service failures would be honest mistakes, made by smart, dedicated people working as hard as they can.

No matter how hard we try, we wouldn’t do better than 99% on effort alone. So we rely on a system completely different from what most organizations do. Same number of people, same number of hours working, 100% accuracy.

We added teamwork to the mix. The type of teamwork and collaboration wherepeople cross-check one another,  speak up when needed, and catch the inevitable slips, trips, and lapses that humans make - to detect and correct errors before the package is late. Or, before the patient doesn’t get antibiotics on time, or doesn’t get an aspirin on check in.

If it’s not working, harder might not be the answer. Creating a culture of accountability might be.

Most of the time, folks in health care think of their job as a set of tasks or actions that take place in a —> [box] <—.

It turns out, though, that if they go upstream and alter the stuff that comes to them in their box, it’s a lot easier to do great work, that is safer and of better quality.

And if they go downstream and work with the people that take care of their patients after the patient leaves their box, the final product is better as well. Now, it’s more of a –> [   box   ] <–. (Note the box is now bigger - with more room to manuever.

A surgeon can consider his work as only being in the box of the operating room. But if he works with the wider perioperative team to systemize the processes to make sure EVERYTHING (antibiotics, equipment, H&P, implants, charts, imaging, etc…) is in order before the patient comes in, his results are better. If he will work with the team to systemize processes for the patient after the patient leaves the OR, same thing.

Too often, surgeons take the attitude that that kind of work on systeminzing processes and improving the collaboration among the wider team is work only for administrators. “Call me when you get it right,” he thinks to himself.

If that surgeon could only see what I see at institutions where we have helped physicians and staff improve processes both upstream and downstream. What a better place to practice medicine it creates. What a better “box” to work in. Cases start on time - every time. Cases go as scheduled. The team is better. Preference card systems work. Equipment is always on hand and no one is rushing out of the core to find missing stuff. Cases are uneventful - they go as scheduled. Little slips and potential mistakes are caught before they become a crisis.

The challenge lies in convincing physicians that spending the effort on the upstream and downstream parts of the work, instead of always assuming that their [box] is just what happens inside the OR, or as a direct result of their actions with a scalpel in their hand. But it is a challenge that can be overcome. and when it is, magic happens in our box.

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We hear a lot about disruptive physicians and Disruptive Physician Policies these days.

As Seth Godin points out in his blog, bad behavior and irrational decisions are almost always caused by fear. If you want to change the behavior, address the fear.

I don’t see that approach to changing behavior much.

In my previous work with airline safety systems, I used to lead what we called “Mediated Debriefs” for cockpit crews that had a total meltdown in teamwork and could no longer fly together safely. Usually the meltdown was caused by disruptive behavior - which can be deadly when experienced in a confined metal tube with wings hurtling through the air at 500 MPH.

After scores of sessions with totally dysfunctional crews, I realized most of the bad behavior stemmed from some sort of fear. That discovery transformed my ability to help the crews get to the root cause of the meltdown and, more importantly, plot a way forward to change behavior.

I wish more folks would try that tactic.

Instead, we ban someone, or we put a letter in the permanent file, or put the employee on a performance improvement plan.

Sometimes asking “What are you afraid of?” is the shortcut in understanding what motivates the behavior you are seeing. Fix the fear - change the behavior.

If you read a book or download a resource from the Internet (e.g TeamSTEPPS from AHRQ) that you want to use to change your organization for the better -  and it fails or doesn’t work for you, then it’s just a another self-help program.

If you read a book or use a resource that actually succeeds in creating a sustainable culture of safety, then the label changes from just another self-help program to a successful change initiative that you want to brag about.

We don’t like programs or projects that fail, because they waste our time, they frustrate us, they are confusing, or they make us feel like we don’t know - exactly - what do next. Self-help projects can often make us feel this way.

On the other hand, a program or resource that resonates with us, that shows us exactly what to do to be successful and then teaches us how to do the things we need to do to be successful, earns a place of trust and confidence. We will tell others about it.

A training consultant who tries to sell you something and fails is a high-pressure salesperson.

If she succeeds in selling you something and that something truly changes your culture, she’s helpful.

The difference between a self-help project and a consultant-assisted project isn’t one of intent. Both are ultimately striving for the same thing.

The difference is in the success, or lack of it.

By the way, the only real help is self-help. Any vendor that promises to create the culture change for you without much effort from you, is making an empty promise that can’t be kept. Truly successful culture-changing initiatives are training partnerships where the health care organization rolls it sleeves up and works alongside the consultant experts. That is the way LifeWings does business. Our mission is to get you to the point where you can help yourself because you can do exactly what we do, as well as we do it.

So, self-help or consultant? Ask yourself which one is most likely to achieve success for your organization?

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This week’s post comes from the monthly CRM Newletter produced by Memorial Healthcare System in Hollywood, FL. Memorial is ranked as the 6th best place to work in health care by Modern Healthcare magazine. The article, reproduced here in it entirety was written by Dr. William Perryman, Chief of Cardiac Surgical Services at MHS. Dr. Perryman’s article will give you a sense of why Memorial is such a great place to work.

“Performing pediatric cardiac surgery in a foreign country with a support team from a variety of centers can sometimes be challenging to get everyone on the same page. This is a similar situation to that often faced by airline crews and was the genesis for the development of Crew Resource Management (CRM).

On a recent trip to the University of the West Indies (UWI) Hospital in Jamaica, we had the opportunity to use CRM during surgery for 7 children having complex cardiac surgery. The OR team had surgeons, anesthesiologists, perfusionists, OR nurses, residents and students from Joe DiMaggio Children’s Hospital, Jackson Memorial Hospital, University of Florida Shands Hospital and host UWI Hospital.

The equipment that we used was, at times, different from case to case and different from MRH (Memorial Regional Hospital). The perfusionists were using whatever cannulae they could find and anesthesia was using drugs, sometimes, with different names than they were used to in US. I was operating with a different faculty member each day or a resident.

As you can imagine, this is a very similar scenario to airline crews who arrive for a flight on equipment that may vary, with a flight crew who have never flown together before and a cabin crew who face the same challenge.

CRM allowed all present to understand each component of the operation, what adaptation might be needed and what specific “stuff” would be required for that particular child. CRM proved to be an excellent solution to an ever-changing operating room scenario and allowed us to leave with all children safely managed through their operations and returned to delighted and grateful parents. CRM also provided a template that could be continued after our departure.”

Dr. Perryman is correct. Airline pilots frequently fly with other pilots and flight attendants whom they have never met before, and with aircraft mechanics, dispatchers, and air traffic controllers whom they have never worked with before.

The Captain of the flight has just a few moments to create an effective team that utilizes expert communication and collaboration skills to detect, catch, and correct the inevitable small mistakes and errors humans make before those mistakes become serious or fatal. The blueprint for creating this expert team from a group of aviation experts is crew resource management (CRM).

As Dr. Perryman’s experience clearly shows, CRM is the blueprint for even widely disparate, international medical experts to creat an expert medical team. If CRM can work in that environment, it can work anywhere.

(Note: This post comes from Steve Montague, one of our Vice Presidents at LifeWings.)

In “Turning Doctors into Leaders,” Thomas Lee correctly notes, “team building is a critical competency for physician leaders.”  While this is clearly a necessity, Atul Gawande illuminates the pathway by which physician leaders will learn to lead; by leading a multi-disciplinary team in the OR, ED, ICU, etc.  The distributed competencies present in a modern clinical context will significantly underperform their joint capability if they are lead in an autocratic style, or not lead at all.  Dr. Gawande points out that medicine is wise to borrow from other professions (such as Sullenberger, et al) and there is a ready model for medical schools to emulate if they wish to adequately prepare tomorrow’s physicians to be servant leaders; the U.S. Service Academies. 

The first step is to clearly articulate the expectation that physicians lead.  For example, if you ask an auditorium of freshmen (or plebes) at Annapolis, “Who in this room is a leader?” there will be a sea of hands up in the air in spite of their lowly status.  Conversely, I never get a similar response from medical students, nor even residents.

Once medical students sign on as future leaders, the medical school must provide a curriculum consisting of academics and low cost of failure leadership opportunities using interdisciplinary simulation.  This allows individuals to experiment and find their specific leadership style. 

Finally, leadership must be evaluated and included in any consideration of residency or fellowship.  If it’s measured, it matters.  Whether leading a multi-disciplinary team, or serving as the leader of colleagues, an admiral or a department chair must know how to lead long before assuming the title.

(Steve is a graduate of the U.S. Naval Academy.)

In addition to my work with LifeWings, I am an international Captain on the MD-11 aircraft for FedEx Express. I’ve been flying professionally for 33 years. Every year for 33 years I have had to undergo a competency check, either in the real airplane or in a simulator. For 24 of those 33 years I have had two competency checks per year in a simulator - for a total of 48 checks.

This week I just completed my annual competency check in the MD-11 simulator, and it was one of the most challenging tests I have ever had in aviation.

What was interesting about this check is that the basic strategy for testing my competency as a captain was completely different from anything I had ever experienced before. For years the approach to testing aviation skills was much like batting practice. Get in a simulator and demonstrate to the check pilot that you could handle a long list of potential malfunctions and emergencies. The list never varied from year to year - engine failures, electrical problems, hydraulic malfunctions, wind shear recoveries, and landings in bad weather - all accomplished at the same simulated airport. 

The disconnect with the real world is that the inability to fly the maneuvers and handle the emergencies tested annually in the simulator are rarely the cause of accidents. Prior to the advent of teamwork training for airline crews, almost 80% of airline accidents were caused primarily by a breakdown in the teamwork and communication skills of the flight crew.

Thus, the check ride for this year had a totally different approach. During the briefing for the test, the company check pilot was very clear the purpose of the event was to check my ability to operate the airplane safely by using both a high level of technical competence and effective teamwork and communication skills (CRM) with my co-pilot. Could we solve complex problems in a challenging scenario by working together effectively while simulating a regular flight from Point A to Point B? No batting practice this time.

In short, could I manage the human factors?

When you think about what really causes airline accidents this evaluation emphasis makes sense.

Our test involved a simulated flight from Taipei, Taiwan to another airport in Taiwan just 30 minutes away. The scenario tested our ability to respond to a potentially deadly wind shear, thunderstorms, an unexpectedly closed airport, holding patterns, a divert to Hong Kong, gusty winds, poor visibility, difficult to understand controller language, an engine failure, another minor engine malfunction, another divert from Hong Kong to an airport in mainland China, low fuel, and an approach and landing in bad weather conditions.

After two and a half hours of intense concentration I was totally spent. Without a technically competent co-pilot, and exceptionally effective teamwork and communication, we couldn’t have carried the flight off safely. Had I not listened to the co-pilot’s inputs and suggestions I would have made a couple of serious mistakes. Had she not listened to me she would have made a few too. 

Together, we crosschecked everything, detected and corrected our small mistakes before they became serious or potentially fatal, and eliminated the human factor of fallibility as a source of undetected deadly error.

We demonstrated how two technical experts could also function as an expert team.

My experience this week makes me think of the application to health care. The data on why medical mistakes happen is almost identical to that of aviation. Seventy to 80% of preventable medical errors have some sort of communication error as the main cause. Almost 70% of sentinel events have a breakdown in teamwork and communication as a primary cause.

If the causes are the same for both professions - the cure might be similar too. A commitment to more and better designed simulation training, and effective teamwork training and checklist usage for everyone will go a long way for improving patient safety and quality outcomes.

Twenty percent of the clothes in your closet are worn 80% of of the time.

Twenty percent of the carpet in your house gets 80% of the wear.

Twenty percent of your friends get 80% of your time and attention.

Twenty percent of your employees or direct reports cause 80% of your headaches.

Twenty percent of what you do in your job every day accounts for 80% of the value you provide to your employer.

You’ve heard of the 80/20 rule before. I’ve blogged about it in a previous post. The correct name of the rule is Pareto’s Law and it affects just about everything we do in life, including leading a successful patient safety initiative.

The amount of time that leaders, managers, and administrators invest in leading the change will amount to about 20% of the total hours invested in the whole initiative. Front line workers - the physicians, nurses, and staff that provide the actual hands-on care to your patients - will account for 80% of the total time a patient safety project requires. The folks doing the daily work of providing care will invest way more hours in making the implementation successful than do the organization’s leaders.

Yet, the 20% of the work in the initiative done by the leaders will ultimately account for 80% of the success of the effort.

It’s really quite simple: No leadership = No change.

The difference between “sorta” successful and “wildly” successful is leadership. Will the organization’s leaders persistently do with discipline and focus the simple, daily actions required to effect sustainable culture change?

This is why LifeWings invests so many hours with an organization’s leaders IN THE BEGINNING of a new patient safety initiative. Leaders must have effective change management skills. They must know what to do, when to do it, and how to do it. Get the leadership actions wrong, or fail to do them at all, and your safety initiative has no chance of success.

Bottom line: Persistently follow the blueprint for leadership actions. Eighty percent of your success depends on it.

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All rules are made to be broken, but here are a few that, if followed, will get your patient safety initiative off to a good start…

1. Waiting until the timing is right and nothing else is going on in the hospital is another way of saying that you’re stalling. Make the timing right.

2. Don’t obsess over the powerful people who don’t get patient safety. Great ideas aren’t anointed, they spread through a groundswell of support.

3. The hard part is finishing, so enjoy the starting part. Persistence is the only magic ingredient.

4. Powerful organizations adore the status quo, so expect no help from them if your idea challenges the very thing they adore.

5. Figure out how long it will take for the safety initiative to spread through the hospital, and multiply by 4. Persistence is the only magic ingredient.

6. Be prepared for the Dip. Folks will lose some interest. Don’t worry, this is natural and you will overcome it. Persistence is the only magic ingredient.

7. Seek out apostles - People who benefit from spreading your idea, not people who need to own it.

8. Think big. Bigger than that.

9. Pick a date to start. Pick a date to see some results. Honor both. Don’t ignore either. No slippage, no extended deadlines. Persistence is the only magic ingredient.

10. Surround yourself with encouraging voices and incisive critics. It’s okay if they’re not the same people. Ignore both camps on occasion.

11. Be grateful you have the opportunity to make a lasting change in the care of your patients.

And most importantly…

Rise up to the opportunity, and do the idea justice!

Hat tip to Seth Godin for the inspiration of making this list.

It is just about time for March Madness, the NCAA college basketball playoffs. This national tournament reminds us that competition is everywhere, even in health care -  although we sometimes forget to notice it.

Examples:

There are ten hospitals in town that provide services in particular medical specialty. One hospital has made an investment in teamwork training and standardized work for its nurses and staff in that specialty. Consequently, the community-based physicians in town that practice in this specialty always have efficient, standardized, high performing teams to work with when they provide care in that hospital. Physicians can get in, and get out - providing great care efficiently. Which of the 10 hospitals has won the competition for attention from the community’s physicians?

There are six ASCs and day surgery centers in town that patients can choose for surgery. One invests in its safety with a real culture-changing safety initiative, has a focus on the patient experience, recruits its patients and their families to be a part of the safety team, and makes its safety and quality statistics available on its web site. Others are muddling through, arguing about the business case for safety, factoring in mistakes and adverse events as part of the cost of doing business in health care, hiding their results under the cloak of secrecy, and doing business as usual. Which one will ultimately command a higher premium for its services while also doing the right thing for its patients?

You have fifty openings for nurses or other staff. You are competing with 8 other hospitals in town for qualified personnel. The working hours and pay rates are about the same all over town. Your nursing turnover rates are the lowest in town. Your employee satisfaction surveys are the highest in town. Your safety climate surveys are the best in town. Your culture of interactive communication between physicians and staff is the most collegial in town. Your core measures are the best in town. Your HCAHPS survey results are the highest in town. Which hospital has the most number of nurses wanting to interview with it?

There are ten new jobs in town for the superstar mid-level administrator who is looking for a new challenge. One hospital offers a culture of accountability where the staff speak up and hold one another to the standards of performance they have all agreed to. It has a commitment to standardized work and is not constantly re-inventing the wheel. All of the managers are committed to giving and receiving objective, specific, detailed, non-defensive performance feedback from one another. It has a history of giving its physicians a seat at the table when new procedures and systems are implemented; it never struggles finding physician champions for its projects. It gives its managers the tools and the freedom to work on interesting projects that improve the safety and quality of care. Where does she choose to apply?

We don’t have to like competition but we must understand that it exists. While certainly not the only initiative available to win the competition, effective patient safety programs give physicians, nurses, staff, administrators, and patients a very compelling reason to pick you and your organization.

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