One hospital I worked with had a series of several serious wrong surgeries. After the third one, and in desperation they called me, asking for an immediate call back. They knew their culture was broken. They knew their checklists weren’t being used correctly, if at all.

It took over 24 months for them to decide to take the steps to fix it.

You don’t need more time, you just need to decide.

Read the history of the original Mac and you’ll be amazed at just how fast it got done. Willie Nelson wrote three hit songs in one day. To save the first brand Seth Godin was responsible for, he redesigned five products in less than a day. Seth says It takes a team of six people at Lays potato chips a year to do one product redesign.

The urgent dynamic in patient safety is to ask for signoffs from your executive team and to push forward, relentlessly.

Keep telling your leaders, “I can make this happen. I’ve got it.”

Seth Godin, one of the best project innovators out there says you can feel this relentless move forward happening when you’re around it. “It’s a special sort of teamwork, a confident desperation… not the desperation of hopelessness, but the desperate effort that comes from being hopeful.”

Your patients are hopeful that you are relentlessly improving how you provide care. Are you?

What’s happening in your unit?

Here’s what Richard Corder on the blog KevinMD has to say about that incident…

“In our hospitals, these “incidents”, these “near misses” rarely get reported internally; the associated press and the national evening news certainly don’t pick them up as front page stories.

If we are obsessed with safety, like the human factors focused airline industry, our near misses and our good catches would be enough for us to stop the line, stand back and work to develop safer systems.

I know that the analogy is not perfect, our clinicians and care givers are tending to the complex human system that we cannot treat like the machine that is a plane, that being said there are lessons to be learned.

So what can leaders do?

Lead a culture where you model that it is safe to speak up and encourage people to call out near misses, report good catches and model the mindset and actions of being personally accountable.

Make it known that while clear roles and clarity around authority are important, everyone is personally empowered to speak up or call an unsafe or potentially unsafe behavior to the attention of their colleagues.

Use all meetings, from the board to the bedside, to tell stories of how a mistake was avoided and how, when things go wrong, you recovered.

When things do go wrong because they will, we are human beings caring for human beings, don’t point fingers and blame people. Own the outcome, work to learn from the failure, apologize, atone and remain open to feedback.

Adopt some of the human error mitigation systems that the airlines have embraced.”

Richard is right on the money with his comments.

“Too rote!” they cry.

“Doesn’t apply here,” they complain.

“Are you crazy? I don’t have time for that,” goes the refrain.

“What proof do you have?” they ask with a sneer.

“Just another ‘project of the month’” they say with a resigned sigh.

But all of this is the feedback we get when we touch a nerve and are doing work that matters enough to care about.

The worst sort of feedback is no feedback at all. That means we’ve created nothing worthwhile at all.

Chief Financial Officers for surveyed hospitals estimated the percentage reduction of operating costs for the next 3-5 years.

The average was set at 11%.

How are hospitals going to do this? Lean + TeamSTEPPS. Lean for process improvement to drive out the waste. TeamSTEPPS (or CRM) to create a culture of accountability to make sure the waste stays driven out.

We typically see an average ROI on Lean process improvement work of 4 to 1. One dollar spent on improving processes return $4 on waste reduction and volume increases.

Unfortunately, you only keep that $4 improvement every year if you have an operational culture where peers hold one another accountable to adhere to the new waste-free, efficient process. Otherwise, your organizational culture will eat your process improvement efforts for lunch. This is one of the true values of an effective TeamSTEPPS program. Tt creates a culture of cross-check, accountability, stop-the-line when standardized work is ignored.

Everyone has processes. Everyone is doing Lean. Everyone has bundles (CLABSI, CAUTI, VAP, SCIP, etc..). Everyone has protocols. Everyone has checklists. Everyone has medical expertise and training. What everyone doesn’t have is “culture.”

Culture is what separates the profitable and on-going, from the broke and going-out-of-business. What are you doing today to change your culture? If the answer is nothing, be prepared to be looking for new employment by 2015.

Mayhem does happen. Even if we don’t want it to. Just look at the amount of patient harm in our nation’s hospitals.

Allstate won’t prevent that harm. But you can - with a really great system of care that has high reliability processes and a culture of safety that holds everyone accountable to use those standard processes.

Mayhem happens. You have the tools to stop it. Time to get busy.

In the learning center where simulations occur, a central observation area is outfitted so that faculty can observe students practicing with the actor-patients; there are one-way mirrors and the technology to support wireless headsets so that instructors can change the audio channels to observe several rooms simultaneously. Rooms are also outfitted with AV equipment and microphones so that every interaction is recorded. This creates a longitudinal database so that students and professors can track their progress and ensure that practice has a positive outcome on student performance in medical school and beyond. This is an important point - practice sessions are taped for study and learning.

Football coaches have long analyzed game tape, but taping practice is actually more important. Part of building a culture of practice is videotaping practice; it sends the message that improvement through practice matters.

Cornell uses the lens of practice and feedback for all aspects of their program.

After each training session the actor-patient breaks out of the role and, using a detailed checklist, gives the medical student three pieces of very explicit feedback. Following feedback from the actor-patient, each student debriefs with faculty for more performance feedback. Finally, the students go through the very painful process fo watching their own video tape. (I know this is painful because this is the exact process we followed when learning how to present new material when I was an instructor at TOPGUN. Fellow instructors played the role of students in a classroom listening to our presentation, and after getting their feedback we received feedback from our instructor on the new material, and finally, we had to watch a video tape of the whole presentation.)

What these new medical students are learning is priceless for success in the new world of health care:

1. Medical skill is not enough. Every clinician must know how to be an expert communicator and how to operate as part of a highly functional team.
2. Practicing together and exchanging feedback builds isolated individuals into an expert collaborative team.

Altogether, the hospital avoided 550 bloodstream infections since it launched the initiative in 2006, an overall reduction of 77 percent, according to the article. Two of the hospital’s units have had more than 1,000 days and more than 800 days, respectively, without a central-line infection.

Hospital officials embraced a variety of infection-avoidance tools, including checklists for inserting and maintaining central lines, and teamwork training for the improvement of communication between physicians and hospital staff.

The tools used by the Children’s were first introduced to health care by LifeWings in 2001. The methodology was refined, studied, published, and made poplar by work done at Johns Hopkins. “Real change rarely occurs overnight. It requires sustained effort and unwavering focus, day after day, month after month, year after year,” Michael Rinke, lead author of the Johns Hopkins study, said in a statement. “It’s a slow, arduous process, but the payoff can be dramatic.”

The $23 million in savings are further proof that patient safety and quality initiatives, when executed successfully, have a significant Return on Investment. it is projected that up to 15% of hospitals will go out of business by 2019. Results like Children’s was able to realize are critical to economic survival.

The challenge for any hospital wishing to implement a truly effective TeamSTEPPS program is that although the documented impact of TeamSTEPPS is desirable, the installation of TeamSTEPPS in hospitals can’t be cost-free, (it can’t be done by downloading free materials from the AHRQ web site) and therefore competes with other hospital (survival) priorities for precious diminishing financial resources.

This is the main reason hospitals should implement the powerful combination of Lean (Toyota Production System) and TeamSTEPPS.

Why? It is easier to gain and demonstrate the financial returns of Lean (see a few at this link). In effect, successful Lean projects fund the TeamSTEPPS implementation to improve the patient care quality/safety that is and should be at the core of every American hospital’s reason for existence.  Besides, the cultural approach of Lean is highly synergistic with TeamSTEPPS, so reinforcing and so compatible that doing both Lean and TeamSTEPPS will be seamless to hospitals.

Not everyone knows how to seamlessly integrate both. LifeWings does.

A new Harris Interactive/HealthDay survey reports the number of people who use retail health clinics has jumped from 7 percent in 2008 to 27 percent.

Why?

Convenience.

People are looking for ways to fit health and wellness into their busy schedules. Hospitals that develop efficient, reliable, fool-proof processes and services with this in mind will build their brand and customer loyalty.

The others will go out of business.

Really.

If you create a culture where the newest, and most inexperienced staff member can have a stop-the-ine conversation with the oldest and most experienced physician, and that conversation is “just the way we do business,” then you have given everyone who works there a real gift. Employee and physician satisfaction improves, staff turnover goes down, and patient satisfaction skyrockets. Your institution becomes the employer of choice.

This is a substantial gift. It’s a gift because as an administrator or leader, you do 80% of the work to make a culture change successful. (If you don’t believe this, you probably shouldn’t be doing a culture change project.) The staff mostly just have to accept your work and believe in where you want to take them.

Unfortunately, it’s actually not that easy to give something substantial away. That’s because accepting it means a change (in practice pattern, responsibility, or worldview (”I’m not just a Tech, my opinion matters and I have a responsibility to speak up.”)) of the person receiving it. It’s stressful.

You see it as a gift (making this a better place to practice medicine), they see it as taking something away from staff and physicians. Once a person or an organization comes to believe that, “this practice pattern is mine,” they erect a worldview around their possession of it. Their ownership leads them to say things like:

1. I just work here.
2. I spoke up before and had my head handed to me.
3. I’m not saying anything, I have to work with this doctor every day and he will make my life miserable.
4. Administration won’t support me.
5. It’s not my job.
6. I’m sure it will turn out okay.
7. She’s the physician, I’m sure she knows what’s best.
8. I’ve always done it this way.

Taking old thought patterns away from staff instantly becomes personal, an act seen by staff as being far greater than living without “the way things used to be” in the first place would be. If they hadn’t done things “that way” before you tried to make a change, the change wouldn’t be that big of a deal.

As humans, we care more about the change being made because we see it as taking something we own from us, and fail to look at the gift we will be getting in return.

You can help with this by over communicating the benefit. You can never stress the benefit too much.