SaferPatients

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.

It is just about time for March Madness, the NCAA college basketball playoffs. This national tournament reminds us that competition is everywhere, even in health care -  although we sometimes forget to notice it.

Examples:

There are ten hospitals in town that provide services in particular medical specialty. One hospital has made an investment in teamwork training and standardized work for its nurses and staff in that specialty. Consequently, the community-based physicians in town that practice in this specialty always have efficient, standardized, high performing teams to work with when they provide care in that hospital. Physicians can get in, and get out - providing great care efficiently. Which of the 10 hospitals has won the competition for attention from the community’s physicians?

There are six ASCs and day surgery centers in town that patients can choose for surgery. One invests in its safety with a real culture-changing safety initiative, has a focus on the patient experience, recruits its patients and their families to be a part of the safety team, and makes its safety and quality statistics available on its web site. Others are muddling through, arguing about the business case for safety, factoring in mistakes and adverse events as part of the cost of doing business in health care, hiding their results under the cloak of secrecy, and doing business as usual. Which one will ultimately command a higher premium for its services while also doing the right thing for its patients?

You have fifty openings for nurses or other staff. You are competing with 8 other hospitals in town for qualified personnel. The working hours and pay rates are about the same all over town. Your nursing turnover rates are the lowest in town. Your employee satisfaction surveys are the highest in town. Your safety climate surveys are the best in town. Your culture of interactive communication between physicians and staff is the most collegial in town. Your core measures are the best in town. Your HCAHPS survey results are the highest in town. Which hospital has the most number of nurses wanting to interview with it?

There are ten new jobs in town for the superstar mid-level administrator who is looking for a new challenge. One hospital offers a culture of accountability where the staff speak up and hold one another to the standards of performance they have all agreed to. It has a commitment to standardized work and is not constantly re-inventing the wheel. All of the managers are committed to giving and receiving objective, specific, detailed, non-defensive performance feedback from one another. It has a history of giving its physicians a seat at the table when new procedures and systems are implemented; it never struggles finding physician champions for its projects. It gives its managers the tools and the freedom to work on interesting projects that improve the safety and quality of care. Where does she choose to apply?

We don’t have to like competition but we must understand that it exists. While certainly not the only initiative available to win the competition, effective patient safety programs give physicians, nurses, staff, administrators, and patients a very compelling reason to pick you and your organization.

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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.

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.

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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.

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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 particulare 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 Johnshon 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.

It’s not only U.S. hospitals that are concerned with improving the safety and quality of health care. I recently returned from Malaysia, where there is great interest in creating a safer experience for patients. During my visit, I conducted workshops for 4 hospitals and the Malaysian Ministry of Health.

One of our first activities was to get to know one another, and for me to understand the competitive and regulatory landscape in Malaysia. So I began to ask them questions about reimbursement rates, Never Events, public transparency of safety and quality data, Sentinel Events, and malpractice lawsuits, etc…

What I disscovered about their country is that few of the patient safety “motivators” that exist in the States are present in that country. There is no govermental or regulatory pressure on local hospitals to improve patient safety. They are not concerned about pay for performance, or lower reimbursements for poor safety or quality. They do have malpractice cases, but the “sue anybody for anything” mindset is notably missing. They do not post their safety and quality data for the public to see. In short, there is no economic pressure on the Malaysians to improve patient safety.

Said another way, the lack of an improvement in safety will not put their business at risk.

Yet, there is clearly a national concern over doing a better job for those they serve, and for no other reason than it is the right thing to do.

Financial return on investment for safety activities is a secondary consideration, if it matters at all.

Honestly, I found it very refreshing to have the opportunity to work with medical professionals who want to do the right thing just because it is the right thing, and not because their actions were monetized, provided an ROI, or because they felt threatened by regulatory or economic consequences.

Another refreshing difference from stateside workshops was the number of practicing physicians in the room. In the U.S., it’s rare to see a practicing physician take time away from caring for patients to invest in patient safety improvements. Most of the workshops we do of this type are filled predominantly with nurses and administrators. In Malaysia, over 50% of the participants were physicians who were taking an active role in leading patient safety initiatives in their hospitals.

Having said that, as the workshoip progressed, it became clear that many of the barriers to organizational change that we experience in the States are identical to those in Malyasia. People are people everywhere - all subject to the universal resistant human reactions to change.

The lesson learned here is that no mater what adversity or barrier you are struggling to overcome in your patient safety change initiative, someone, somewhere in the world is experiencing, or has experienced, the same thing. And, that means there is best practice available to overcome your challenge. We just have to find the best practice and learn from others.

My experience in Malaysia proves yet once again that there is very little new under the sun. When we realize that and seek out those who have already walked our journey, we learn and improve much faster.

I agree with most Americans that we need healthcare reform. As I travel around the country helping hospitals implement best practices in their patient safety programs, it is clear to me our present system has some major flaws. Costs, for everyone involved, spiral upward every year - yet most hospitals are “break even” businesses at best. In many states, more than half the hospitals are in the “red” and others limp by with 1% profit margins. And, too many of us don’t have access to the care we need.

Further, as a Christian and man of faith I would argue that, as a matter of responding to our moral imperative to take care of our fellow man, ensuring access to quality health care is a proper role for government and consistent with biblical teaching.

But, in their rush to reform healthcare as we know it, and in the face of growing opposition to their 1000 page bill, I believe Congress has created a reform package that needs serious rework. Here’s why.

First, Congress has rejected every amendment to protect the consciences of medical providers- doctors and nurses who, respecting the tenets of their faith, would choose not to participate in providing abortions or “end of life services.”

I do not argue with the right of patients to seek such services if they desire, nor the provision of those services by healthcare professionals who wish to provide them. But, I believe it to be unfair to make our nation’s physicians and nurses violate their conscience and their first amendment rights, or to make them choose between their faith and their careers.

Over the years I have worked with many Catholic hospitals and systems. Catholic facilities constitute 13% of our nation’s hospitals. How will these faith based institutions be affected by the current bill? Will the bill, as is, force them to perform such procedures? What percentage of them would choose to close rather than violate the tenets of their faith?

I have also seen first hand how Catholic systems take care of the poor and unemployed. What will be the effect on this safety net? Will government run healthcare be able to take up the slack?

Second, medical mistakes and errors. As I look at the error rates in single payer, government run systems around the world, the numbers of adverse outcomes due to medical mistakes seem to be on the rise - not decreasing. In the U.K, France, and Switzerland, for example, recent studies showing the effect of errors on their healthcare system are startling. I don’t see anything in this bill (like the FAA mandate of CRM training for the airlines) that really addresses the potential for an increase in error.

My next concern is fiscal responsibility. The Congressional Budget Office says the bill now in Congress would add $1 trillion to the federal deficit over the next 10 years. While we should move forward on reform, the process should consider the cost to our nation and future generations. What can we afford? What other programs should be cut? How can we, as a country, live within our means?

I don’t profess to have the answer to what healthcare reform should look like and how we should pay for it. But I do want reform. However, a bill that violates freedom of conscience, erodes the dignity of human life, or leads to a budget busting government takeover of healthcare is not the reform we need.

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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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