SaferPatients

Crew Resource Management, or team training, is not a new topic in health care. Health care has even adopted its own name for a CRM-based patient safety project - TeamSTEPPS. Whatever you call it, it’s the idea that health care as an industry can learn a lot from the aviation industry - specifically that many of the concepts used in creating a culture of safety in the U.S. commercial airline industry can be used in health care to improve patient outcomes.

The question is often asked “Where is the data that proves this approach?” A study that provides the data to back up this notion is reported in  American Medical News.

The research, published in the  Archives of Surgery, followed caregivers who had taken a course titled “Lessons from the Cockpit,” which attempts to relate errors in aviation with medical errors and teach how to avoid them. After studying 857 participants of the six-hour course since 2003, researchers concluded that teaching health care workers the principles of crew resource management has a positive effect not only on patient care, but on workers’ perception of the culture of safety and self-empowerment.

Some of the most striking results include the use of preoperative checklists (75 % of participants were using them in 2003, and by 2007 100% of participants were using them). Self-initiated incident reports rose from 709 in the first quarter of 2002 to 1,481 in the first quarter of 2008.

You can read more by checking out the American Medical News article.

The Patient Safety and Quality Health Care journal reports that 90% of hospitals include patient safety as an integral part of their strategic plan and, even in this difficult economic climate, 53% plan to spend more money on patient safety initiatives than they did last year.

I wonder, given the data that verifies the CRM approach, how many will invest in training their staff with the teamwork and communication skills used by all high-performance teams?

Here is an interesting blog post from Seth Godin, author of Linchpin and Poke the Box (two of my favorite books). Seth says…

“Thousands of doctors have signed up for a service that, among other things, they can use to try to prohibit patients from posting reviews. You can read a bit about it here.

In Iowa, in a surprisingly similar move, the state government is moving ahead with a law that will make it a crime to take or possess videotapes of factory farming that might harm the commercial interests of the farmer.

In both cases, an organization is trying to maintain power by hiding information from the public. Can you imagine being arrested for possession of a photo of a pig?

It’s easy to argue that from the public’s point of view, laws like this are a bad idea. The public certainly benefits from the outing of bad doctors and from the improved hygiene of factory farms. In that sense, it’s unethical for doctors and legislators to subvert their responsibilities by ordering the un-empowered to shut up.

I think it’s interesting to think about from the doc’s point of view (and the chicken farmer), as well. The temptation is for those in charge to defend the status quo by fighting transparency. This ignores a simple truth:

When book reviews are posted, book sales go up.

Yes, the argument of fairness matters.

(Yet) it turns out that transparency increases profitability.

Here’s the thing: when consumers get used to transparency, they’re also more interested in the quality of what you sell, and are more likely to willingly pay extra. They’ll certainly cross the street to buy from an ethical provider. And once people start moving in that direction, the cost of being an unethical provider gets so high that you either change your ways or fade away.

Inundate us with images of cleanliness and quality instead of blacking us out. Don’t race to the bottom (you might win). Instead, force your competition to race you to the top instead.

[Aside: the same objection happened when we started regulating hygeine in restaurant kitchens. Yes, it got more expensive to clean the pots and kill the rodents, but it was okay, because post-Duncan Hines, demand for quality went up enough to more than pay for it.]

The same argument holds true for doctors. Once information about good doctors becomes widespread, patients will be more willing to seek out those doctors, rewarding the ones who consistently take better care of their patients. The entire profession doesn’t suffer (we’ll still go to a doctor) merely the careless doctors will.

One more: A leading politician in India is arguing that bribery (in certain transactions) ought to be legalized. Why? Because if the briber feels free to rat out the bureaucrat, bribery goes down.

In all three cases, sunlight is an antiseptic and the marketplace rewards those that behave–and the entire market grows when the standards increase.

Consumers and those that want their admiration ought to reward those in favor of transparency.“

I love Steve Pressfield’s book, Do the Work. It’s a short, simple, incredibly motivating manual on how to overcome the resistance that all great improvement projects meet. Here is a short excerpt on his comments about passion - and passion’s role in overcoming resistance.

“Picasso painted with passion, Mozart composed with it. A child plays with it all day long.

You may think that you’ve lost your passion, or that you can’t identify it, or that you have so much of it, it threatens to overwhelm you. None of these is true.

Fear saps passion.

When we conquer our fears, we discover a boundless, bottomless, inexhaustible well of passion.”

Want to find a way to energize your patient safety or quality improvement program? Find a way to tap into the passion of your staff to heal patients. Isn’t that why they got into health care to begin with?

Nothing is as ever as persuasive to your staff- not your logic, not your cogent arguments, not the peer-reviewed data -  as when your passion for the project connects to their passion for caring for people.

You know you will meet resistance whenever you are trying to effect change. When you meet it, and find yourself hesitant, ask yourself, “What, exactly, would I do here if I wasn’t afraid?” Whatever the answer is - do it. When you conquer your fear of what others will say and do, you’ll find your passion for the task will grow. Others will see it and tap into it. Then you’ll have some momentum.

Go find your passion.

There’s incessant pressure on companies like mine (LifeWings) to get better at selling our services. To put it bluntly, I am on a mission to change the world (or at least the level of safety with which health care is delivered). I really need my team to figure out how to approach, educate, close and support health care facilities to convince them to become our safety partner and use our products and services.

But what about the health care systems, hospitals, clinics, surgical centers, and practice groups that are doing the buying? Business research reveals that the typical organization with more than 1,000 employees has, on average, 21 different people involved in each sale of over $25,000.

The typical big health care facility’s org chart is a mystery, the buying process is a mystery, and there never seems to be an end to the roster of meetings and people. Sometimes it’s almost as though these organizations don’t want to buy anything.

Consultants like LifeWings are not the enemy, and choosing to work with us isn’t charity. The transaction happens because it will benefit both of us.

Unfortunately, the byzantine maze, lack of information, and endless circle is a real barrier to success for both sides.

First, this is exceptionally inefficient. Second, it drives away the great opportunities for sure and permanent improvement in culture and performance. It also leaves health care organizations with only  the sales-focused, ultra-patient consultancies willing to put up with 21 different people and a million meetings. LifeWings is not that consulting company. We don’t even talk about sales revenues - we focus on the number of health care partners we have. I figure that if we help more hospitals next year than we did last year measurably improve their safety and quality, the dollars will ultimately take care of themselves. Besides, I am 56 years old and I am not ultra-patient, my clock is ticking. Patients are suffering now from inadequate safety systems and frankly I don’t think I have time to wait for a million meetings.

If you want to discover new, proven methodologies to increase safety and quality in this era of ACOs, data transparency, and pay for performance, you’re going to need better training partners and consultants. One way to do that is to streamline your buying process and let the folks selling to you know how it works. We’re not the enemy. In fact, companies like LifeWings are your best source for off-the-shelf improvements and innovation you can start using tomorrow.

In this age of health care reform, whoever buys proven innovation the best, wins.

Here are some thoughts on how you can buy better when you are interested in getting help from an outside company:

1. Give them an org chart.

2. Give them an overview of the best way to sell to you.

3. Tell them about successful sales to you and how they were made.

4. Reward your employees when they help a new vendor make a sale that really benefits you.

5. Hassle your employees if they become a roadblock or lie to your vendors.

6. If a vendor asks, “Are you serious about buying from us,” the answer should either be, “Yes,” or “Perhaps, tell me more,” or,  “No, thank you.” Whatever the response - mean what you say.

At LifeWings we want to work with organizations that really want to work with us. Together, we can change the world. Life is too short to have it any other way.

A recent study of surgical procedures in Colorado hospitals and health care facilities turned up an alarming number of cases where a surgery was performed on the wrong patient or on the wrong body part. The study, reported in the October issue of the medical journal Archives of Surgery, analyzed a database of over 27,000 adverse occurrences reported by physicians between 2002 and 2008. The findings reported 132 wrong surgeries.

The root cause of these errors was communication problems in all of the wrong-patient cases and 48.6% of the wrong-site cases.

In 72% of the cases, the physician did not participate in the Time Out.

Two things we can learn from these facts:

1. If you are using your surgical safety checklist as a glorified form of a grocery list or as an audit tool, doing a Time Out with a checklist will not fix the communication problems that lead to wrong surgeries. A properly formatted and executed checklist is a trigger to have a scripted conversation among the surgical team about the upcoming procedure. To have a scripted conversation you must have multiple speaking parts for different members of the team. If your idea of a speaking part is for them to say, “I agree,” in response the the information rattled off by the circulator  - you are missing the boat. That is not a scripted conversation.

2. If you want to ramp up your chance of having a wrong surgery even though you are using a checklist-driven Time Out, continue to accept the refusal of physicians to get involved in your checklist. In the airlines, the effective and complete use of checklists are the responsibility of the team leader - the Captain. He calls for and leads most of the checklists used in the cockpit. Checklists are his tool to manage the workflow and lead the team. The most effective checklist-driven Time Outs are surgeon-led. The science is settled - more surgeon involvement leads to fewer wrong surgeries. Less surgeon involvement leads to more wrong surgeries.

Bottom line? Effective surgical checklists are led by the surgeon in such a way as to have a scripted conversation with the team about the impending procedure. Anything less that that target exposes your surgical team to more risk of a wrong surgery.

Overcoming Organizational Resistance

When  inspiration, then success, then recognition and reward for the improvements we have made have come and gone, who will still love you—and whom do you love?

Only two things will remain with us when we cross to the other side: the creative genius (yes, genius) with which our Creator endowed us, and the hearts of those we love.

In other words, what we do with the abilities we have been given and those for whom we do it.

Each of us is unique -  equipped for this moment and our role in health care reform with a set of work skills, life experiences, and passions. Are we doing the most we can for this mission with what we have?

When resistance comes, and it surely will, remember why you are doing what you are doing, and for whom you are doing it.

Don’t let yourself be stopped.

Overcoming Organizational Resistance

My favorite quote, one we use in every Leadership Development Institute with health care leaders, is from Calvin Coolidge:

“Nothing in the world can take the place of persistence. Talent will not; nothing is more common than unsuccessful men with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent.”

In 11 years of helping health care organizations all over the world, I have worked with all kinds of leadership teams with all kinds (or not) of resources -  world-famous academic medical centers; giant world-class metropolitan hospitals; prestigious, rich, profitable, money-is-no-object institutions; simple, very rural, out-of-the way 10-bed facilities; poor inner-city clinics. Some have been wildly successful changing their culture and dramatically improved patient care, others not so much.

One thing I know beyond a shadow of a doubt. You cannot predict success on the basis of education, talent, or resources. I agree completely with President Coolidge, “Persistence and determination alone are omnipotent.” It is the only predictor of success.

Be Stubbornly Persistent

Once you commit to action with a change initiative, the worst thing you can do is to stop.

What will keep you from stopping? Plain old stubbornness.

I like the idea of stubbornness because it’s less lofty than “tenacity” or “perseverance.” You don’t have to be a hero to be stubborn. You can just be a pain in the butt.

When you’re stubborn, there’s no quit in you.

You’re in until the finish.

You will sink your junkyard-dog teeth into Resistance’s butt and not let go, no matter how hard he kicks.

You will be successful.

Overcoming Organizational Resistance

Here are three of the dumbest people ever: Charles Lindbergh, Steve Jobs, Winston Churchill. Why? Because any smart person would have understood how impossibly difficult were the tasks they had set themselves. A smart person would have never accepted the task.

A degree of willful ignorance and arrogance are the patient safety officer’s and quality improvement specialist’s indispensable allies. She must be purposefully clueless enough to avoid obsessing on how difficult her enterprise is going to be—and cocky enough to believe she can pull it off anyway.

How do you achieve this state of mind? By staying “stupid.” By not allowing ourselves to over-think.

A child has no trouble believing the unbelievable, nor does the genius or the madman. It’s only you and I, with our big brains and our tiny hearts, who doubt and over-think and hesitate.

Don’t think. Act.

We can accomplish nothing until we act. And when we act, oh, what we can do.

Hat tip: Steve Pressfield in his wonderful book, Do the Work.

When you start a new safety or quality initiative you are going to get resistance. It’s a fact of life. Why are you surprised when you get it?

When you do get it, when Dr. ‘Big Producer’ or Nurse ‘I’ve-Been-Here-30-Year’ says “That will never work,” or, “We don’t do it that way here,” - don’t take it personally.

This is tough advice. Are you supposed to take it like a filing cabinet would take it?

Sometimes it seems as though the only way to take it is personally. That physician who doesn’t like your protocol (your best work) or that nurse who has been your friend for 20 years who doesn’t want to run with you any longer…It’s never personal. It’s never about you. How could it be? That person doesn’t truly know you, understand what you want for the organization or hear the conversation you have in your head about the right thing for your patients.

All they know is themselves and what they think.

When someone fights you and your project, when they refuse to listen to evidence, or even badmouths you or your work, it’s not personal about you. It’s personal about them. Their agenda, their decisions, their story.

Do your work, the best way you know how. It’s the right thing for your patients.

Is there any other option?

Looking for an excuse for failure is often the first warning sign that a safety project or quality initiative is in trouble. Sometimes, in our work with health care organizations we find the excuse making begins before the project does.

In these cases, our coaches will sense that the organizational subconscious has already started looking around for an excuse, deny-ability and something to blame before they even begin their work with us.

Members of the leadership team are already saying, quietly, “Well, we can start this, and if it doesn’t work perfectly, we can point out it was the … (insert standard excuse here).” Then, as the project team cranks up, senior administrators appear to be seriously interested in the outcome, and inevitable resistance occurs, project members begin to add to and refine the excuse list, reminding themselves of all the factors that are out of their control.

Project teams that have a built-in all-purpose excuse (poor payer mix, rural location, community physicians who never participate in quality initiatives, teaching hospital, budget, that’s the way it’s always been done here, etc…) often end up failing–they have an excuse ready to go, have used the excuse before, and find it’s easier to back off when the going gets rough. After all, “We’re different from other hospitals. We knew that couldn’t work here.”

What happens if you relentlessly avoid using excuses at all?

Our successful projects are filled with people who are obsessed with avoiding excuses. If you relentlessly work to avoid opportunities to use your ability to blame your failure on the common excuses, you’ll succeed beyond your wildest imagination and never actually need to resort to any excuse.

Is your safety or quality initiative where you want it to be? if not, are you subconsciously making an excuse?

Stop it.