Breakout sessions at last week’s Lucian Leape Forum included Dr. Lucian Leape himself, Paul O’Neill, Former Chairman and CEO, Alcoa, 72nd Secretary of the US Treasury and more. I had the long-awaited pleasure of hearing Paul O’Neill speak in person, during his breakout session entitled, Operationalizing, Disseminating and Implementing Joy & Meaning In Work and Workforce Safety, along with Julie Morath, RN, MS, President & CEO, Hospital Quality Institute of California. O’Neill’s unwavering standards and expectations in business, and for healthcare, have been an inspiration for many. Therefore, it came as no surprise that he seemed irritated with our progress to date, pulling no punches when asking the group how many of us in the room knew the real-time facts about injury to the people who do the work in our hospitals, and, did a system currently exist to provide that information with a 24-hour lapse? No one in the room raised a hand, and he shared that only 6/100 in a recent audience responded affirmatively to the same questions.
“We’re too far away from this type of excellence,” he said, following with a story that while at Alcoa, the company’s screen saver included real-time safety data. When a particularly concerning near miss appeared on his screen one day, O’Neill picked up the phone and called the team in Russia where it had occurred, asking for more information about what had happened. The personal attention to this near miss resonated throughout the organization, furthering the culture and behaviors that make organizations stronger. It’s this type of response and awareness to healthcare professional harm, as well as patient harm, that will move us to where we need to be.
“Why can’t we do this (in healthcare)?” was O’Neill’s resounding and animated challenge, many in the room knowing full well why we have not. Healthcare culture, leadership that says one thing but fails to support the necessary changes at pivotal moments, inertia–all of these however, are choices made by leadership. Either you’re in or you’re out.
Much of O’Neill’s breakout session was based on the LLI white paper, Through the Eyes of the Workforce, a must read for anyone serious about improving the quality and safety of care. Key takeaways from this breakout, as well as the summary session that followed, include:
- It will be very challenging to protect patients if we first can’t protect our own.
- The physical and psychological safety of our healthcare workforce is pivotal to ever improving the quality and safety of care.
- Real leadership is enabling not controlling.
- A leader’s first responsibility is to his/her people.
- Safety is not negotiable – it’s not a trade-off. You figure out how to pay for it. A pre-condition is that people who work ‘here’ will not get hurt.
- Habitually excellent organizations don’t “report” – they share information and act in a timely way when things go wrong.
- The response is key when people do share information. You can shut down a reporting culture in a heartbeat if you criticize someone for what/how/where they shared information.
- How would your healthcare workforce answer O’Neill’s 3 Questions: 1) Am I treated with dignity and respect by everyone each day? 2) Do I have what I need so I can make a contribution that gives meaning to my life? 3) Am I recognized and thanked for what I do?
We were reminded that it is hard to make a business case for healthcare professional safety, but data also shows that unhappy, un-empathetic, uninspired or unrecognized healthcare professionals directly impact the safety of patients, which directly impacts the “business case” in immeasurable ways. Too often, many in healthcare have observed our colleagues defend or excuse sub-optimal results, or continue to look the other way when observing behaviors that clearly are not in the best interest of colleagues or patients. O’Neill’s unwillingness to compromise standards or expectations is not only inspiring, those values created a company in Alcoa with a safety record that set the bar for his industry, as well as other high-risk industries. O’Neill left the group with many pearls, but following is one that particularly resonated along with advice from the world of storytelling:
“Organizations are either habitually excellent or they’re not – there’s no in between,” said O’Neill.
“Do or not do, there is no try,” fictional sage Yoda advises via the story world of Star Wars.
It is time for healthcare to do differently.
The 7th Annual National Patient Safety Foundation and Lucian Leape Institute Forum and Gala was held last week in Boston, gathering patient safety leaders together to share knowledge, recharge and re-energize their efforts in making care safer for healthcare professionals and patients. The opening keynote, Using Informal Influence to Drive Positive Change in Healthcare, was given by Andrew Knight, PhD. Assistant Professor, Organizational Behavior, Olin Business School, Washington University. Knight has studied innovation implementation, leadership and teams in high risk environments, such as the surgical suite, ICUs, Emergency Departments and the military.
Knight’s talk provided a number of take home tools for healthcare leaders to approach internal change with new power. He supplied a different lens through which to view company politics, one that allows for consideration of “the other” versus leaving a footprint on even your mother’s forehead to reach the top. He shared insight into the influence skills and the collaboration across teams necessary to move quality and safety initiatives forward. And, he stressed that data alone has not been the sole catalyst for the large-scale adoption of change needed to make the healthcare workplace as safe as we need it to be, using the tragic story of Ignac Semmelweis as evidence. Many are familiar with Semmelweis’ story–the doctor who discovered hand washing as a “cure” for the high number of deaths related to childbirth in Vienna clinics. His findings at the time went against the medical community’s thinking of the day, with physicians even taking offense at the request to wash their hands before caring for a patient. Unable to convince, or influence, others of his findings during his lifetime, Semmelweis was ultimately committed to a psychiatric hospital at the age of 47, and beaten by guards two weeks after his arrival. As the story goes, Semmelweis died shortly after from the same infection he was trying to protect patients from through hand washing. This simple, cost-effective step in the delivery of care at the desired 100% adoption rate still eludes health systems today.
Additional takeaways from Knight’s talk include the following. He is an excellent speaker and the topic couldn’t be more timely for healthcare.
- When it comes to navigating the waters of company politics, do you consider yourself an innocent lamb, a straight shooter, a survivalist, company politician or Machiavellian? Knight asked the group to respond via a text message survey. Results showed a normal distribution, the majority claiming to be survivalists with one Machiavellian in the group, prompting Knight to tongue-in-cheek, warn all to watch their backs.
- A more realistic view of company politics was offered, such as: Instead of considering what tactics might be used to influence someone, walk a mile in their shoes to understand exactly how what you offer might affect another. Or, instead of kissing up to those in power, feel free to compliment those you admire!
- Driving positive change is hard work! A 2005 study showed more than 50% of attempts to implement innovations end in failure, and that over $500 Billion is wasted annually on new technology implementations, according to Morgan Stanley
- To implement change, groups outside one’s direct circle of influence need to buy-in, collaborate, support, and supply resources to be successful. Influence skills can help gain the buy-in!
- Informal influence at all levels of the organization is what makes for the successful adoption of new initiatives.
- A numeric equation to map the political landscape related to change was provided, quantifying the amount of current support for any given project, by any given stakeholder, indicating likelihood of success.
- “For most change initiatives we need commitment. Compliance is rarely enough.”
It has been some time since we have written about the concept of flow on ETY (see What is Flow, and How Can It Improve Healthcare?, Achieving A Flow State in Healthcare: Can We Do It?), and after recently finding Warren Miller Entertainment’s website once again, I was reminded that flow is not far away if one remembers to seek it.
As defined by Mihaly Csikszentmihalyi, being “in flow” means achieving a state of mind, or being, where time stands still and an individual is so in tune with the moment, and so engrossed in the activity, that all awareness of the self or self-consciousness is overtaken by the activity at hand, and a feeling of well-being is experienced. It could be likened to mindfulness at its most intense level–something we are trying to embed within the healthcare culture. We had asked: Could learning to find flow in our healthcare work return the joy and meaning that Dr. Lucian Leape speaks of, and as a result, improve the patient’s experience of care?
As you ponder these thoughts on a summer Friday, enjoy the following peek at Warren Miller’s 2014 annual kick-off to ski/snowboard season–always a visual example of flow in my mind:
John Nance, a leader and pioneer in both aviation and medical safety and quality–and for the past 18 years, a familiar face to television audiences as the Aviation Analyst for ABC News and Good Morning America–joined us this year in Telluride for our Patient Safety Summer Camps. John, along with other international patient safety leaders, have come to Telluride over the last 10 years to share their knowledge and passion for patient safety and patient-centered care with the rising leaders of healthcare. It is with a heart full of gratitude that we have welcomed Lucian Leape, Cliff Hughes, Paul Levy, Helen Haskell, Rosemary Gibson, Kim Oates, Richard Corder, David Classen, Carole Hemmelgarn, Bob Galbraith, Gwen Sherwood, Patty Skolnik, and so many other wonderful “teachers” each year to our faculty. Many come to CO every summer because they believe so strongly that we must Educate the Young if we are to deliver the highest quality, safest care possible to our patients.
At this year’s Summer Camp, John spoke about the similarities between aviation and healthcare, highlighting the importance of Teamwork, Effective Communication, Leadership, and the power of Debriefing after all activities. His educational messages came to life when one of our faculty, Dr. Roger Leonard, boarded his flight back to the east coast. Roger’s story, shared below, exemplifies almost every skill John spoke to our group about just days ago. While there is still much work ahead for those of us on the Quality and Safety mission, we sometimes forget all the good things our professional caregivers do in the face of very dysfunctional health systems and decreasing resources. Thank you Roger, and a heartfelt thank you to all caregivers who make a difference each and every day in the life of another.
“Not Retired,” Previously posted on the Telluride Summer Camp blog, by Roger Leonard MD
My flight from Denver to Washington Dulles was late to depart due to thunderstorms. We left at 10:30 pm and I tried to sleep, but was sufficiently alert to hear the page at approximately 2 am: “Any medical personnel on board?” The flight attendant escorted me to first class where a passenger had what she thought was a seizure. And she was probably right – only it was due to sudden cardiac death. No pulse, no breathing, unconscious. Male, perhaps 45 yo, looked fit, no companion.
The flight crew assisted me in lifting him into the aisle. Because of their training, by the time that I started CPR, one of the attendants had the AED out and started handing me the pads for placement. V.Fib. We shocked once and got a rhythm. He started to breathe and the oxygen tank was right there. He had a rhythm, he had a strong pulse, he was breathing. I said: “This is good.”
I tried to get a BP, but the sphygmomanometer was broken. We got another emergency kit and it had a cuff that worked – BP ~115 systolic. I admit that I struggled to get accurate BP recordings because my ears felt like I was 12 ft underwater from the altitude change (and probably a need to see an audiologist). We sorted through the medical kits and I finally found the NS under the neatly packed top layer of drugs. Found the tubing, tried to maintain sterile technique, and got a decent IV in his forearm while fighting postural movements of his upper extremities. Then came VF arrest #2 and #3. Shock, shock, back to NSR. I was able to push lidocaine 100mg IV.
While scrounging around the medical kits, I found an endotracheal tube. To me great relief, he kept breathing on his own and had good color. I hadn’t intubated anyone in 40 years. Meanwhile, the pilot was diverting us to Louisville where the EMS team met us. You know how tight the aisles are. We managed to get him onto a back-board, but then had to tilt him to nearly 90 degrees to turn the corner. He was on his way to the hospital and after refueling, we were on our way to Dulles.
I got applause and handshakes as I returned to my seat. How strange! After our 4 days together, I could only think that “it’s about the patient, not about me.” I was particularly aware of the calm and effective work of the flight attendants on our team.
In Louisville, we needed new fuel and a new flight plan. So, with the extra time I asked to gather all the attendants and debrief. What went well? 1) We successfully resuscitated a passenger with SCD at 30,000 feet. 2) An AED was mission critical and the staff was trained in its use. 3) Our treatment lasted about 45 minutes; we were calm; we explained what we were doing among the team; no one panicked including the other passengers. 4) EMS personnel were at the door upon the Captain’s diversion.
What didn’t go well? 1) the first BP cuff malfunctioned. 2) I struggled with obtaining accurate BPs. 3) I was slow to get what I needed out of the medical kits; the IV bag, couldn’t find a tourniquet 4) The patient had not regained consciousness upon departure, but groans were evident.
How can we improve? 1) preventive maintenance (PM) on medical equipment. 2) I suggest a digital BP cuff that reads the result without my impaired use of the stethoscope. 3) We should ask nearby passengers to vacate their seats so that we might spread out the medical equipment and drugs. 4) have EMS use an entrance that avoids tight turns, if possible.
We become physicians to heal the sick, relieve suffering, comfort those in need, and occasionally we may save a life. I do not know the outcome for this gentleman. I am worried; yet, I am hopeful. I strive to role-model humility. Yet, transparency reveals that I am proud to be a physician and proud of our team of strangers at 30,000 feet.
The success of our Telluride Roundtables and Summer Camps over the last ten years can be credited, in large part, to the generous time and participation of our faculty made up of patient safety leaders from around the world. The students and residents chosen to participate through the Telluride Scholars Program have been the beneficiaries of the knowledge and experience these great leaders and teachers all are so willing to share each year. Rosemary Gibson, Rick Boothman, Cliff Hughes, Kim Oates, Peter Angood, Kevin Weiss, Bob Galbraith, David Longnecker, Helen Haskell…the list goes on and on.
In the summer of 2011, students had the great fortune of working with Lucian Leape, who joined the faculty of our Telluride Patient Safety Summer Camp. It was an honor to have him with us, and something our alumni–young and old–will always remember. Lucian’s focus that week was managing disruptive behavior and returning joy and meaning to the healthcare profession. The photo included captures him in action doing what he does best–educating the young. As we begin a new calendar year still struggling with many of the issues Lucian called to light in his 1999 seminal work, I believe his teachings on Joy and Meaning in the workplace are more important today than ever before, and that those strategies will play an even greater role in preventing harm to our patients.
Caregivers at the frontlines consistently put considerable energy into achieving the highest quality, safest care possible for their patients in the face of considerable economic pressure and evolving healthcare models. We expect so much from our caregivers, and they far too often extend themselves beyond what is healthy–physically, emotionally and mentally–to meet the growing demands of the new healthcare. Lucian’s work on joy and meaning in the workplace is based on Alcoa leader Paul O’Neill’s premise that every employee should be:
As healthcare leaders, we need to clear a safe path for all frontline associates to be respected, supported and appreciated. At the same time, we also need to eliminate the disruptive behaviors that have plagued healthcare for far too long. This year, a driving focus should be on ensuring those well intended healthcare professional are elevated, their humanness not only accepted but also protected through just culture approaches and human factor partnerships that mitigate and finally eliminate the potential for patient and employee harm while embracing a workplace built upon the high reliability foundations of a true learning culture.
As Lucian continues to remind us, it is our dedicated caregivers working at the bedside that need to feel safe — to know that their effort is appreciated and celebrated, that they have our support, and are respected for the work they do.
Please enjoy this message from the National Patient Safety Foundation and Dr. Lucian Leape. This video serves as the foreword to the NPSF Online Patient Safety Curriculum.
Have a safe and happy holiday weekend!