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.

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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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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A survey undertaken by the Institute for Safe Medication Practices last fall has shown that the current economic climate has forced staff cuts, reduced the amount of technology and equipment that hospitals can purchase, and negatively affected the culture of safety by reducing the amount of time staff members have to report errors. Nearly 850 people took the survey and of those, 41% said the economy had a large to moderate negative impact on medication safety in particular.

Some specific findings concerning medication safety include:

• Forty-two percent of respondents said the staff person who dedicates time to medication safety (either a medication safety officer or quality improvement specialist) has had hours cut or his or her position completely eliminated.
• Less attention is being paid to the purchasing of safe medication equipment, such as using multi-use vials instead of single-use.
• Caregivers are more apt to rush drug administration practices as well as have less time to educate patients about their medications.
• Pharmacists are less likely to have a clinical presence on patients’ units.

If not the economy, the stressor would be something else. Health care reform, reimbursement reductions, nursing shortages, and staff turnover all could easily replace (or add to) the economy as a stressor to your health care system. Nothing ever stays the same. It is not a question of “if,” but a question of “when” the next stressor will hit.

Despite the ever-changing gale-force winds of stress blowing their way, all high reliability organizations (HRO) have a solid safety system hardwired into their very foundation. They don’t depend exclusively on the extraordinary efforts of excellent staff to fend off errors. HROs give their capable staff an underlying safety system of accountability, leadership support, just culture, safety tools like checklists, and data scorecards that protect the integrity of their operations from the buffeting winds of change.

Do you have such a system?

If not, I predict more mistakes in the future of your organization.

In my last post, I talked about making an emotional connection with your colleagues when describing the goal of your patient safety initiative. Seth Godin made a wonder blog post on this very issue. He said,

“Relying too much on proof distracts you from the real mission–which is emotional connection.”

Read his entire post at this link.

Any hospital wising to implement a sustainable culture of safety MUST have effective change management skills among its leadership team.

One of the first and most critical elements of effective change management is the need to identify and articulate, as clearly and forcefully as possible, the need to ‘do something different’ in order to assure survival. 

That “need to doing something different” is the “burning platform.” Your organization is on it, and if you don’t do something different NOW, the platform will burn up and destroy everything on it.

If you need help determining your “burning platform” to propel your change initiative forward, perhaps the pending health care reform movement will provide one. Here are the common threads in the reform discussion:

1.  The poplar estimate is that an additional 30 million insured healthcare consumers will flood into the present health care system and infrastructure as a result of these reforms.

2.  The ‘quid pro quo’ of expanding the pool of insured people in the U.S. (and significantly increasing the demand for healthcare services) appears to be a long term series of reimbursement reductions of approximately $150 billion over the next 10 years - an estimated $2.7 million in annual concessions per hospital!

3.   With the increased demand, your system of care will be stretched to the max. If it is not already prepared for the crush of new business with a well designed safety system supported by a true culture of safety, your errors and adverse outcomes will increase.

4.  Payers will increase their resolve and enforcement of policies of not paying for errors or shoddy care. They will have to wring cost reduction out of the system to pay for the reform. Not paying for errors and mistakes will be a point of emphasis.

5.  Under an avalanche of new users, and unprepared by having well designed safety systems and a strong culture of safety, many serious errors will be made by health care facilities. Those will be prominently reported in the press. Just as in the National Health Service in the U.K., it will seem like a cottage industry has sprung up around reporting heinous mistakes made by ill prepared health care organizations. As they say in the press, “If it bleeds, it leads.”

In summary, the typical U.S. hospital will see significantly higher demand for services but receive less reimbursement for care. Many hospitals will not be prepared for this “new normal” with an efficient, safe system of delivering care and will rapidly lose money and market share. Their survival will not be assured.

This situation is a true ‘burning platform’ for working smarter and safer, not harder!

One undeniable truth is that human beings are not infallible and will make errors. Human beings under the stress of doing more with less will make even more errors. If you are not thinking now about how to change your culture to create a safe, efficient system of care in your facility, when will you start?

Act now to assure your survival - invest in a culture of safety.

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Creating and implementing checklists to fix flaws in work processes is the “buzz” in health care right now. Fueled by the success of the WHO Surgical Safety Checklist in reducing post surgical infections and deaths, the mistaken view of checklists as the “magic bullet” for improvements in care is becoming more pervasive. 

After 10 years of experience helping hospitals create and implement effective checklists, one thing we know at LifeWings is that checklists, if done right, have their place and can significantly contribute to improving performance and care, but they are definitely not a magic fixall.

One common myth that reduces the magic of checklists is the idea that it is easy to take a successful checklist produced in another facility and by other people and just “drop it in” to your situation in your hospital. That rarely, if ever, works. There is no buy in, no investment, and no customization to your unit’s particular needs and work flow. Even the WHO checklist says on the very bottom of the sheet that individual customization of the checklist is encouraged.

Every checklist or safety tool must be created by the people who actually do the work - and not by administrators or managers, or worst of all, by people at another institution who have no idea what goes on in yours.

Research by the Robert Wood Johnson foundation and Plexus Institute on the concept of Positive Deviance supports this point. These entities funded a study on the work process improvement methodology called Positive Deviance (PD). PD is a concept of process improvement that solicits ideas for solving a problem from those who deal with that problem every day. It encourages the workers who actually do the work to think of a solution that might be considered “out of the box,” but nevertheless one that just might work.

This approach is the essence of Kaizen from the Toyota Manufacturing Process (Lean). It overcomes the natural human resistance to change by allowing frontline workers and their peers to solve their own work process problems. Thus, there is investment in their solution.

The concepts of Kaizen and PD are the key components of the methods LifeWings uses to help hospitals create and implement their own safety tools like checklists, communication scripts, handoff forms, and teamwork algorithms. We know from years of tough, hard-won experience that this approach works best of all.

So it’s not surprising the study from the R W Johnson Foundation reveals that using Positive Deviance to lower MRSA rates has succeeded. Their success with this approach was announced at the annual scientific meeting of the Society for Healthcare Epidemiology of America . The study began in 2006 and introduced the idea of Positive Deviance into three hospitals from different parts of the country. 

A team from the Centers for Disease Control and Prevention analyzed the data from these facilities to show a reduction in MRSA rates between 26 and 62%.

Proof that the best way to improve work processes is to make sure the people who actually do the work create the tools that improve their work.

It’s not only U.S. hospitals that are concerned with improving the safety and quality of health care. I recently returned from Malaysia, where there is great interest in creating a safer experience for patients. During my visit, I conducted workshops for 4 hospitals and the Malaysian Ministry of Health.

One of our first activities was to get to know one another, and for me to understand the competitive and regulatory landscape in Malaysia. So I began to ask them questions about reimbursement rates, Never Events, public transparency of safety and quality data, Sentinel Events, and malpractice lawsuits, etc…

What I disscovered about their country is that few of the patient safety “motivators” that exist in the States are present in that country. There is no govermental or regulatory pressure on local hospitals to improve patient safety. They are not concerned about pay for performance, or lower reimbursements for poor safety or quality. They do have malpractice cases, but the “sue anybody for anything” mindset is notably missing. They do not post their safety and quality data for the public to see. In short, there is no economic pressure on the Malaysians to improve patient safety.

Said another way, the lack of an improvement in safety will not put their business at risk.

Yet, there is clearly a national concern over doing a better job for those they serve, and for no other reason than it is the right thing to do.

Financial return on investment for safety activities is a secondary consideration, if it matters at all.

Honestly, I found it very refreshing to have the opportunity to work with medical professionals who want to do the right thing just because it is the right thing, and not because their actions were monetized, provided an ROI, or because they felt threatened by regulatory or economic consequences.

Another refreshing difference from stateside workshops was the number of practicing physicians in the room. In the U.S., it’s rare to see a practicing physician take time away from caring for patients to invest in patient safety improvements. Most of the workshops we do of this type are filled predominantly with nurses and administrators. In Malaysia, over 50% of the participants were physicians who were taking an active role in leading patient safety initiatives in their hospitals.

Having said that, as the workshoip progressed, it became clear that many of the barriers to organizational change that we experience in the States are identical to those in Malyasia. People are people everywhere - all subject to the universal resistant human reactions to change.

The lesson learned here is that no mater what adversity or barrier you are struggling to overcome in your patient safety change initiative, someone, somewhere in the world is experiencing, or has experienced, the same thing. And, that means there is best practice available to overcome your challenge. We just have to find the best practice and learn from others.

My experience in Malaysia proves yet once again that there is very little new under the sun. When we realize that and seek out those who have already walked our journey, we learn and improve much faster.