I feel uncomfortable in the space between the tried-and-true way something has been historically done, and the risk and uncertainty associated with finding a better way to do it…
The conversations about what is not working, knowledge of the outcomes that are not being achieved and the belief that there is a better way (that is often already being practiced or imagined by a small number of courageous souls) is exciting and full of possibility and potential… I am naturally drawn to what is on the horizon, the potential of a brighter future…
And it is unsettling and downright scary as I put at risk the “way I’ve always done it” and lean into something that is uncertain, unclear and without guarantee.
It is uncomfortable to both yearn for something better and deal with the private tension that not changing is often easier and less risky than changing… And yet I know, deep down in my bones and from my own life experiences, that much of what I enjoy today is because I took a risk to walk away from the past, took a risk to try something new and let go of something that wasn’t working based on a promise or a belief of a better, brighter more value/principle aligned future…
The phrase “the tension of the and” comes to mind in this uncomfortable space. Easy enough words to say, and yet, for me, uncomfortable to practice and bring to life both personally and professionally.
A mentor of mine reminds me that unless I now have elastic arms… I need to let go of what I am holding onto to reach what I’m trying to grab…
A crude analogy perhaps but the root of my discomfort is the uncertainty in the space between these two states… the known and the unknown.
The actions associated with change are uncomfortable.
And, knowing and sharing this does not make it any easier but it does make the journey more enjoyable.
It is more enjoyable because it is easier for me to articulate what is happening, easier to recognize and appreciate the feelings (my own and those around me), easier in some ways to craft and share the narrative of the why behind the change and the hope for a better future and easier to seek out support, advice and help from those around me as we journey forward and change.
I’m comfortable being uncomfortable.
I had a routine GI procedure three weeks ago. You know the drill; “after the prep, the procedure is a piece of cake…”
I had a great experience. The results were clean and benign! The staff were friendly, the center was clean, the nurses were kind and professional and explained everything well. The doctor was personable and had an appropriate (enjoyable for me) sense of humor. Everything ran on time and my ‘competent adult’ escort got me home before lunch time – I was starving!
Life quickly returned to its ‘pre-prep’ normalcy and the procedure was a distant memory. Or so I thought…
This morning a 37-question paper survey arrived in our mail box, asking me to share my “thoughts and feelings”.
My immediate reaction of wanting to recycle this piece of ‘junk mail’ was curtailed by my morbid curiosity to re-examine this antiquated and ineffective means of gathering feedback.
Do our hospital and health system leaders really believe that this is an effective way to gather feedback about my experience of the care that I received? I can’t remember what I had for breakfast this morning and you’re asking me to rate the “Attractiveness of the Surgery Center” from three weeks ago.
This is absurd on so many levels!
I really don’t recall how attractive the surgery center was, nor do I really care.
I care that your staff were kind, compassionate and didn’t keep me waiting. I care that you knew who I was and did the correct procedure on me. I care that you explained what you were doing to me and that you all seem to know what each other was doing, apparently enjoyed working together, had the equipment to do your jobs safely and effectively and seemed to be committed to taking care of me as a priority.
Listen. If you really want my feedback, if you really want to know my thoughts and feelings, do what our vet does after my dogs have a visit; call me that night or the next morning. If I’m not available chat with my wife (she was the competent adult that picked me up…), trust me, she will know whether my experience with you, your facility and your caregivers was anything other than stellar.
This would also allow you to determine whether I was suffering any post-procedure discomfort or pain. That call would also be an appropriate time to ask me whether I had any questions about the procedure and you could remind me about any follow up that I needed to remember.
If you can’t afford the time for a person to make a call, then send me a text or an email with half a dozen quick questions. In fact, that might be better, then you’d have the real time data to inform any changes to your operations or any service recovery for your patients.
The 80’s called, they would like their survey back!
We can do better than this, our patients and caregivers deserve better than this!
P.s. send the pager and fax machine back too…
It’s been more than five years since I dipped my toe into the world of blogging when I wrote – “The Emperor is Naked! Taking risks to reduce risk…”
The title was a clumsy headline intended to grab your attention.
The point then is the same as it is today so here’s a reprise – Still Naked
The fear of speaking up and being vulnerable is getting in the way of delivering safe and effective healthcare. The fear of speaking up is paralyzing leaders and their teams.
Coming over that fear requires bravery and as my friend and mentor Steve Farber (author of the Radical Leap) would say, vulnerability:
“Vulnerability aids human connection, and connection is the conduit for energy. Pretense of invincibility builds walls and creates distance between human hearts.”
Time to close this distance. Time to speak up. Time to get naked…
In the first blog in this series I shared Robert Frost’s poem “The Secret Sits”
“We dance round in a ring and suppose,
But the Secret sits in the middle and knows.”
I suggested that the “Secret” is the person at the center of care. The patient, their family, and their caregivers are sitting “in the middle” and knowing what they need and want but they lack effective ways of sharing this, and provider organizations’ currently have ineffective means of capturing this feedback.
In the second and final part of this series, “The Secret” and Improving the Experience of Care, I offer some ideas for how leaders in healthcare can improve the usefulness of data capture to improve the patient experience.
I’d really appreciate any comments, feedback and other ideas that this post prompts.
The question remains, are you dancing around the ring and supposing, or are you listening to the secret?
I recently used Robert Frost’s poem “The Secret Sits” as a blog writing prompt…
“We dance round in a ring and suppose,
But the Secret sits in the middle and knows.”
In the blog I suggest that much of what we do as leaders in healthcare (the dance) and what we measure in healthcare are disconnected from what our patients and staff really want and need (the secret sitting in the middle).
I was recently in a hospital conference room preparing for a leadership meeting; the walls were papered from floor to ceiling with graphs, tables and charts… a “loud” visual statement that a myriad aspect of operations was being measured and reported. During our meetings I dug a little deeper, listened to the leaders, caregivers and patients, and then looked a little closer at the “scores” on the walls.
Outcomes, as measured and reported, apparently hadn’t changed much over the past two-years… It was not lost on me either that this conference room that is billed as the “control-center” of operations felt lifeless and soulless… For an organization committed to ‘health’ and ‘care’, this felt like a disconnect.
And I’ve seen hospitals that are listening to the “secret”. They are measuring, reacting and acting differently. They are breathing life into their data and working on ways to make it as real-time as the work and care that it is intended to measure. Outcomes are improving, care is safer and the experience of those caring and being cared for is markedly improved; so I am optimistic and incredibly hopeful that we can rethink what we measure and how we act. How we lead.
Check out my blog “Improving the Experience of Care” (first in a two-part series) on our company’s site. I’d love your thoughts, comments and ideas:
- Are we measuring the right things in healthcare?
- Is chasing an improved CAHPS score, or a better CMS Star Rating, the right way to drive change?
- Can we measure everything that matters?
- How do you measure a healthy, effective and respectful culture?
- What’s the secret that you’re dancing around?
I recently re-read the words of broadcast journalist Walter Cronkite, “America’s healthcare system is neither healthy, caring, nor a system.”
This sad and yet truthful reflection, combined with the reality that our founding partner, mentor, friend, student of the classics, and therefore a natural etymologist – Tim Sullivan – had me thinking about the origination of the words we use in healthcare.
Two words in particular; hospital and patient.
A quick scan of history reveals that in the middle ages hospitals were in fact almshouses for the poor, or hostels for pilgrims. The word ‘hospital’ comes from the Latin word hospes, meaning an entertainer, host, a visitor, a guest, a friend bound by the ties of hospitality.
Another noun derived from this is hospitum which came to mean hospitality, or the relationship between guest and shelterer. Hospes is also the root of the English word host.
In my travels, I have witnessed many hospital leaders who have lost sight of the fact that our roots go back to providing shelter for the poor, a resting place for those on pilgrimage, and completely lost sight of the tenets of welcoming patients as guest or friend.
The English noun ‘patient’ comes from the Latin word patiens, the present participle of the verb, patior, meaning ‘I am suffering’.
The hospital should be a place of respite for the friend that is suffering.
I think it is fair to say that if you’re leading in a hospital (regardless of size) you’re contributing to the running of one of the oldest aspects of the “service industry”. Yet at many hospitals, we seem to have left the consistent delivery of this ‘service’ completely up to chance or in the care of those without the training and skills necessary to deliver upon the promise.
Service – from the old English meaning religious devotion or a form of liturgy, from old French servise or Latin servitium ‘slavery,’ from servus ‘slave.’ The early sense of the verb (mid-19th century) was ‘be of service to’, or ‘to provide with a service.’
What service is your institution providing those who are suffering that come to your hospital for care and cure?
Do you insist on telling your patients and communities why they should be satisfied with your ‘service’ because of how safe you are, what good ratings you get, or how qualified your staff are?
Or are you listening to those you are called to serve in order that you might better deliver the service(s) they need?
Your patients want to feel welcome, be treated kindly, understood, healed, cured, communicated with (not to), and they don’t want their time to be wasted.
The rest (the safety, the expertise and the qualifications) are a prerequisite – foundational and non-negotiable.
Are you listening to those you serve?
My wife and I recently watched as our eldest child headed off to college for the first time, as he read this letter the night before he left he commented that these were good “life” reminders, I agreed, and so share the letter here:
August 28, 2015
My dear sweet Harrison,
I’ve noticed that the mornings stay darker a little later and that the evenings are drawing in, and I am reminded that this is nature’s nod to the fact that everything has a season, and that everything must end and begin again. Just as I know that the seasons change, I’ve known since the day we brought you home from the hospital, that this season of you being a daily constant in our home and our lives would end and that your new beginning, in college, would start.
The time has come my love – the freedom that has excited you and that you are so ready for is here, and yet this same freedom is one that I have very mixed emotions about.
I have both dreaded this moment and been incredibly excited for it.
I think I’ve privately dreaded this day since I first held you almost nineteen years ago. As a parent you learn the difficult lesson that raising children is in fact to embrace a love that is built on the reality of constantly having to let go of things, of constantly having to let go of you. Letting go of you as your learned to crawl, saying goodbye to your little clothes, dropping you off at pre-school, waving the bus goodbye, watching you go out with your friends, and watching you drive away from the house with your brand new license.
Your mom and I have also learned that the deep love that we have for you has changed us as people. You have added an indescribable richness to who we are as you have grown, challenged, tried, failed, argued, agreed, laughed, cried and blossomed as our “beautiful boy”
And so here we are, on the verge of this next chapter of your life, and as the page turns we are as excited to watch you embrace it, as you are likely to go grab it.
And yet I have this mix of stuff going on… I know you won’t be very far away, but emotionally I’m going to miss having my “little man” around. It’s going to hurt because I know we have to say goodbye to a chapter of our lives that is closing; leaving us with the memories, the mementos, the pictures and the stories; but it is over, it is done, it is closed, it is time.
While I will work hard not to cry tomorrow Harrison, you know me as well as anyone and you know that I’m proud of my emotions and share them unconditionally with you. I will work hard not to cry because this is an exciting happy time (the mix of stuff…) and yet as I write this I have become overwhelmed with tears and the desire to hold you so tightly, to remember all that we did together, the adventures we had, the plans we made and even the things that we never quite got to…
I remember you in the hospital in Beverly, hiding in the dryer in Manchester, building walls in Rockport, sailing up to Maine, treehouses in Amherst, snakes in the kitchen, tongues on lamp-posts, your bravery leaving Amherst, a wooden boat project in the backyard, running in Chicago, and fishing in Ipswich, and I remember laughing, crying, running, playing, learning and living with you as you grew up to be the college bound adult that stands before us, and I miss you Harrison. I miss you so very much.
Watching you learn and grow continues to be one of the greatest blessings and experiences of my life, so as I reflect back on all that you have given us, the lessons you have taught us and the example you will continue to be for all those blessed to be a part of your life, I wanted to share with you some guidance as you navigate this next chapter, some choices and some reminders…
Some choices – remember they’re exactly that, choices:
- Smiling OVER scowling
- Working for it OVER wishing for it
- Optimism OVER pessimism
- Owning it OVER making excuses, blaming others, complaining or gossiping
- Being kind OVER being unkind or rude
- Believing in your abilities OVER believing in your insecurities
- Hugs OVER handshakes
- Loving yourself OVER beating yourself up
- Being your own hero OVER waiting for a hero
- Doing what’s necessary OVER doing what’s easy
- Living for today OVER living for someday
- Being vulnerable OVER being perfect
- Living with purpose OVER sleepwalking through life
- Talking to people OVER talking about people
- Being happy OVER being right
- Have goals and review them
- Use logic and reason AND listen to your gut and your heart
- Admit when you’re wrong
- Praise others – privately and publicly
- Be appreciative – say “thank you”, even better, write “thank you”
- Ask for help, remember that you are a work in progress
- Love life and let it show – be honest with your emotions and bring them with you
- There are no limits to what you can do – remember: “if it is to be it is up to me”
- You are empowered – take a risk, speak up, be brave. It’s OK if your hands shake and your voice quivers. Be brave, speak your heart.
- Take time for you – rest, relax, restore, and exercise
- People and relationships are everything – stay in touch, reach out, lift others up, help people succeed, pick people up
- Be mindful and take action – if you see something, say or do something.
- Strive for purpose, find your passion. Do what you do with love, energy, audacity and proof
- Remember that the small things are the big things
- Above all, remember that you are a work in progress, you are blessed and you are forgiven.
Harrison – you will find your own guides, reflect on your own words of wisdom, and learn your own lessons (you already have many of them under your belt…) and I know you’ll be searching for your own answers along the way at Emmanuel, but please also know that if you ever need help, advice, a shoulder to cry on, or an ear to listen, that I am always, always, always here for you.
What I have shared with you is what guides me. I work hard to live up to it every day, and every day I fall short, but that’s OK. Reaching out for advice, help and inspiration is not a sign of weakness my love, it is a sign of strength.
Time will slip by, the next chapter will end I suspect more quickly than the last.
This time is yours, you’ve earned it, give it as much as it will give you. And remember, as a wiser person than me once shared, “There is no grand prize at the end of your life, no all-expense paid trip to utopia. This is your final destination, this is your life. The prize is here, now, in every breath you take, every new friend you make, every kiss, every hug, every challenge, and every exciting piece of information you discover.”
Godspeed little man! Breathe it in, savor every sip, enjoy every moment! Oh the places you’ll go!
I love you,
The language we use and the hierarchy that this supports is at the core of creating, leading, and sustaining a safe culture.
The words we use
Listening to the faculty and the future (students) at the Academy for Emerging Leaders in Patient Safety (#AELPS11) over the past three days, I have heard several comments and engaged in more than one conversation regarding hierarchy, ego, and language as barriers to safe care.
During some of these discussions I heard myself and others say things like, “Communicate down to the housekeeper” and “escalate this up to the board”. While I think these comments are made with no malicious intent, and often find myself thinking and saying these things, I firmly believe that we need to be more mindful of what this “directional” language promotes.
When I listen to this language, I hear us unintentionally reinforce professional elitism. The language implies that the housekeeper is at “the bottom” of our organization and that the board member is at “the top”. Perhaps I’m reading too much into this but having served in both roles, and having been on the receiving end of these conversations for many years, I believe that this language promotes the belief that the housekeeper is at the bottom of the hierarchy and not an equal voice or participant on the care team. The more we think and speak like this, I believe, we are at risk of discounting the input of those at the lower end of the equation, as well as elevating opinions and ideas of those “at the top”, often at the expense of safe care to patients.
Listening to the team
One story we heard here was the tragic story of Lewis Blackman – a poignant reminder of the aforementioned point was the nutritionist recognizing that Lewis had not touched his food, and yet nutrition orders never changed. Did the nutritionist notice, and wonder why? Was he or she empowered to voice concern, and what might have happened had that been the case?
The care team in healthcare is made up of everyone that interacts, communicates and cares for the patient and their family. The professionals serving in the housekeeping department may spend more time in a patient’s room than many of the clinically trained team on any given day. Ensuring that these team members are engaged, respected, and listened to as valuable team members is a critical component of safe care.
Perhaps it is time that we re-think the structure and hierarchy of traditional healthcare environments
The need for a structure and redesign
I acknowledge that we need some organizing structure to run our teams and organize [lead] our organizations. That said, what we presently have in many healthcare organizations seems to be getting in the way of supporting an innovative, just, safe, learning culture.
In the words of Malcolm Gladwell from his book, What the Dog Saw, “If everyone had to think outside the box, maybe it was the box that needed fixing”. I am also reminded about the words of Don Berwick regarding system design, “Every system is perfectly designed to get the outcomes it is achieving”
It is fair to say that our current healthcare system, if designed to get the outcomes we’re getting (estimated 400,000 lives lost a year from preventable error) needs to be redesigned.
A different approach
I recently read about an alternate approach to organizing an organization, the idea is called Holacracy and was coined by Brian Robertson. This is an alternate way of running an organization, modeled on some concepts that are being adopted more and more by innovative, forward thinking leaders. For example, peer-to-peer business models have changed how we get from A to B (Uber) and have revolutionized finding a place to stay while on vacation (Airbnb). These “disruptive” companies have started re-thinking their internal structures and have abandoned traditional top-down hierarchies, controls and processes. This approach to running an organization removes power from a management hierarchy and distributes it across clear roles, which can then be executed autonomously, without a micromanaging supervisor.
What’s interesting is that instead of the anarchy and chaos that one might expect, the work is actually more structured than in a conventional company, it just looks much different. With Holacracy, there is still a clear set of rules and processes for how a team breaks up its work and defines its roles with clear responsibilities and expectations.
David Allen, the author of Getting Things Done, summarizes adoption of this approach like this: “Holacracy is not a panacea: it won’t resolve all an organizations tensions and dilemmas. But, in my experience, it does provide the most stable ground from which to recognize, frame and address them.”
Perhaps we’re ready for a different way to organize and deliver healthcare. Perhaps we’re ready to rethink our hierarchies, controls and processes.
Perhaps healthcare is ready for a little Holacracy.
Change and personal accountability in health and care!
Standing on the shoulders of the rebels, the crazy ones, the trouble makers and the boat rockers – these are the folks that I am blessed to call my friends and my colleagues; these are the people that push the envelope for change, that embrace the hard work and the ones I love!
Here’s to Colin Hung, Linda Galindo, Helen Bevan, Tracy Granzyk, Dave Mayer, Michael Bennick, Paul Westbrook, Paul Levy, Katy Schuler, Steve Farber, Jake Poore, Diana Christiansen, Jason Wolf, Coleen Sweeney, Carol Santalcuia, Jason Gottlieb, Chris McCarthy, Kip Durney, Jim Rawson, Debra Barrath, and many, many more.
Changing the culture of healthcare takes a village of the committed, personally accountable, energetic, loving and audacious. I love these change agents!
Please join us on March 24th 20:30 EST (8:30 pm) on Twitter for a tweetchat #hcldr
Last speaker of the day
Several years ago I found myself in the audience of a quality and safety conference at Harvard University. The last speaker of the day took the podium with little fanfare and no slides. What a welcome change…
With his very generous permission I’d like to share my memories and notes from that day, the lessons and leadership “keys” he shared then, ring true now, and continue to resonate with me.
And now for something completely different…
Mike Dowling is the President and CEO of the North Shore-Long Island Jewish Health System (NSLIJHS). Prior to becoming president and CEO on January 1, 2002, Dowling was the health system’s executive vice president and chief operating officer.
Mike served in New York State government for 12 years, including seven years as state director of Health, Education and Human Services and deputy secretary to former governor Mario Cuomo. He was also commissioner of the New York State Department of Social Services. Before his public service career, Dowling was a professor of social policy and assistant dean at the Fordham University Graduate School of Social Services and director of the Fordham campus in Westchester County.
Mike presented at the Eleventh Quality and Safety Colloquium (Cambridge MA – August 14-16, 2012) – my notes summarize his comments. Without any slides, Mike shared “7 Keys” to creating a “Premiere Healthcare Organization” by stating, “NSLIJ is not there yet, but we are on a journey toward this, and I’d like to share it with you…
Have a coherent idea of where you want to end up – a clear VISION
- Not just the “what” but the “why”
- You must be able to engage EVERYONE’S head and heart in the VISION – in the “why…”
Have a positive attitude
- Be optimistic and believe that it is possible – a “can do” attitude
- Be responsible for outcomes and model personal accountability – “if it is to be it is up to me”
Have a complete commitment to transformation
- Be ready to think differently – we CANNOT be risk averse
- Be open minded – healthcare is NOT unique – exceptional, high-quality organizations are NOT industry specific
Engage and develop EVERYONE
- Lead a continuous culture of learning
- Be mindful of who you hire, who you promote, who you let go
- Remember: People + Values + Behaviors = SUCCESS
- Use simulation
- Make a core part of your curriculum mandatory
- Break down silos and train people across disciplines
- Manage your board and medical staff
- Change how we do medical school training
Become deeply consumer focused
- Everyone you serve is more educated and informed than ever
- Expectations are constantly changing
- Constant communication of the “why” from #1
- Top down, bottom up, side to side
- Face to face, electronic, multi-media, print, etc. etc.
- You CANNOT over-communicate
Most of all – remember that:
- we do great work every day in healthcare!
- we have much to be proud of!
- we do make a difference!
Mike closed his remarks with the words of Sir Winston Churchill, “Success is going from failure to failure without losing enthusiasm…”
Thank you Mike, you continue to inspire and encourage!