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.)

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.