SaferPatients

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.

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.

�

Surgeons involved in the WHO Surgical Safety Checklist research project were asked if they would continue to use the checklist after the research project was complete. Eighty percent (80%) said it was so benefical that they would continue to use it in their practice.

Twenty percent said “No” - they didn’t need it.

The follow up question asked, “If you were the patient, would you want your surgeon to use the WHO Safety Checklist?” This time, a lot of the surgeon’s resistance melted away. Ninety-four percent (94%) said in effect, “Yes, my surgeon should use the checklist if operating on me.”

I wonder what their patients would say if they knew their surgeon was one of the ones who didn’t want to use the checklist personally, but wanted their own physician to use it when operating on them. I think the question might go something like this, “If using the checklist is good for you when you are a patient, why isn’t it good for me when I am your patient?”

Data like this demonstrates a truism that I have stumbled onto in my work helping hospitals implement effective checklists…

Human beings, even physicians, make their decisions to do something on an emotional basis and then seek data to support the decision they have made.

The survey results from the surgeons’ involved in the WHO study show all of us that logic and data don’t always carry the day in convincing others to support our change initiative. Think about it, these are surgeons involved in a hugely successful world-wide study producing peer-reviewed data showing a 35% decline in complications and deaths. The data is near conclusive. (As Al Gore would say, “The science is settled.”) Yet, 20% of the physicians involved said they wouldn’t continue to use the checklist.

These results reveal that we should never forget the power of the personal and emotional factors needed to motivate others to change.

When recruiting support for your change initiative - whatever the project may be - never forget to answer the age old question for your colleague, “What’s in it for me?” (WIIFM) Make sure that answer is something that affects them personally and on an emotional level.

This concept is one we devote quite a bit of time to in our Leadership Development training when implementing LifeWings in a hospital. The ability to communicate your project goals in a meaningful, and ultimately successful way by simultaneously combining data, logic, and emotions in your appeal is a critical leadership skill.

If you don’t have that level of communications skill, or ignore the power of the emotions in your project communications, you cripple the chances of success for your initiative.

�

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.