SaferPatients

(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.)

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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Pareto’s law is never more in evidence than in the process of leading a patient safety initiative. You remember Pareto’s Law - the 80/20 rule?

• 20% of your employees cause 80% of your headaches;
• 20% of the carpet in your house gets 80% of the wear;
• 20% of the clothes in your closet are worn 80% of the time.

In any successful change initiative, only about 20% of the work will be done by the organization’s leaders.

However, that small percentage of the total hours spent working on the initiative will account for 80% of the success of the project.

Leadership is the critical key. No leadership - no success.

Success depends then on leaders doing the right things the right way. This is the value of the LifeWings Leadership Development Institute. This workshop is where we teach leaders the science of culture change. It’s the “how-to” manual. Here, they learn exactly what steps must be done on Day 1, Day 10, Day 30, and Day 60 of the project - and all the days in between.

One of the questions that always comes up in the workshop is “Where should I spend my effort in persuading others this is the right thing to do?”

This is an important question. Leaders only have so much time to invest in the initiative. Where can they focus their persuasive power and energy to get the most effect? Get the answer to this question wrong and the chance of success is crippled.

The work leaders do when spreading the word about a culture-changing patient safety initiative is aimed at one of these four groups in the organization:

• Physicians and staff who are currently undecided - they may become champions, but are not yet;
• Critics - those that would speak ill of you and the project, and need to be converted;
• Friends and supporters - those that might have jumped on board. For the most part they are along for the ride, but will show real buy-in now and then;
• Fans - members of your tribe, supporters and insiders. They “get-it,” love what you are trying to accomplish, and rave about the possibilities.

Leaders intrinsically already know the truth: you can’t focus on all these groups at once.

Depending on who you are - your personality, your DNA, and your past experiences, you already have a “default position.” You will be drawn to work with one of the four groups. You will lean toward them without thinking.

Leaders that are a marketers at heart will be evangelical and focused on the “undecided” at all costs… they’d rather convert a new supporter than revisit an old one.

Other leaders want the comfort of already being surrounded by supporters and friends.

Most of us will automatically shy away from critics. Who needs the aggravation?

Before you invest any time and persuasive energy, run down the list above. How can you optimize the time and effort available for the project you truly care about? How much would the support of one of these groups be worth to your initiative’s success?

Here’s a hint: a new true fan is worth a thousand times as much as a slightly mollified critic.

It’s Pareto’s Law all over again. Twenty percent of the types of people in your organization will be responsible for 80% of your success.

Leaders, spend your valuable time and energy on them.

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.

I have a friend, Gene,  who was once the Commanding Officer of a U.S. Navy aircraft carrier - the Captain of the ship. And what a ship an aircraft carrier is. The ship alone is as long as the Empire State building is tall, with a flight deck the size of several football fields. it takes over 5000 sailors to keep it operating. It’s a floating city capable of sailing the high seas at over 30 miles per hour. Not counting the 100 or so airplanes it carries, it is a billion dollar asset of the U.S. government. Throw in the value of the airplanes that operate from its deck and it becomes a priceless instrument of U.S. power projection and policy.

The command of such a ship is a coveted prize among officers in the Navy. There are fewer than 10 operational carriers so there are very few “Carrier Captain” slots available to the 65,000 officers in the U.S. Navy. For a Navy pilot, it is one of the few routes to becoming an Admiral. Miss out on being selected as the Captain of a carrier and your chances of wearing the stars of a general officer are slim.

My friend’s command of the carrier’s helm ended badly. One night, while he was fast asleep in his at-sea cabin just aft of the bridge of the ship, the Officer of the Deck, a lower ranking officer in charge of the ship during the Captain’s absence, violated the Captain’s standing orders and commanded the carrier to turn off the plotted and authorized course. The ill-advised turn put the carrier directly in the path of a freighter and caused an at-sea collision and millions of dollars of damage.

Despite being asleep and not on the bridge at the time, and despite the fact his junior officer directly violated his standing orders to make no turns without first awakening the Captain, Gene was immediately relieved of his command by the Navy brass. Another Captain assumed command the very next day. Gene’s career was derailed and he retired from the Navy shortly thereafter.

Unfair? Perhaps, but his sacking was perfectly consistent with the long standing Navy tradition of holding the Captain of the ship solely responsible for what happens to the ship under his command.

My profession, commercial aviation, has a similar and firmly established tradition. The Captain is solely responsible for what happens to an airplane under his or her command. (See FAR Part 91.3.) That tradition has even been codified in the Federal Air Regulations which govern how commercial airliners are operated. Your co-pilot, mechanic, or flight attendant may in fact be the one who makes a mistake putting your passengers in peril, but once the airplane backs away from the gate, the Captain is the one held responsible by the FAA.

There has been a lot of debate within healthcare whether such a tradition and policy is possible in health care. Is the surgeon, for example, to be held responsible for anything that happens to his or her patient in the OR - even if the mistake harming a patient was made by a nurse or surgical tech?

While aviation is not perfectly analogous to healthcare - the roles and chain of command are less distinct, and it is sometimes unclear just who is really in charge - the level of reliability and safety achieved by aircraft carriers and commercial airlines is in part a result of the concept of holding the Captain of the ship ultimately responsible for what happens on his watch.

After ten years of helping healthcare adopt the best practices of high reliability organizations (HROs), I believe healthcare institutions that strive to uphold this tradition have a better shot at creating a culture of safety.  Holding the “Captain of the Ship” responsible is a best practice of HROs.

Whether it is the U.S. Navy, commercial airlines, or a hospital - one thing we know is this: the Captain can’t do it all by himself. There is just too much to monitor and cross check alone. He or she needs the efforts of a well trained team that communicates and collaborates well. If the Captain is going to be held responsible for all outcomes under his command, he will do well to work just as hard at being an effective team leader as he does at his technical skills. The willingness of the team to “have his back” in all situations is directly related to his ability to create and manage an effective team.

Captains, be forewarned. Scream, belittle, ignore, or micromanage at your own peril. Those behaviors leave the needed teamwork stranded at the dock and put your crew members, passengers and patients in peril.

Ultimately they may leave you relieved of your command.

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