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.
Reflecting on our first day of the Academy for Emerging Leaders in Patient Safety and I am feeling blessed for the insights, the lessons and for the reminders.
Yesterday morning we watched the Lewis Blackman Story – we were fortunate to have Helen Haskell with us, Lewis’ mother, who graciously and bravely answered our questions, provided more insights and shared the reminder that this November marks the fifteen-year anniversary of the death of Lewis.
I’ve seen this video more than a few times and to be honest was thinking to myself that there was not much more to “learn”. How wrong was I?
Re-watching this emotional story I was abruptly reminded that the stories of communication failure, mis-diagnosis and poor communication are as real and relevant today as they were fifteen years ago, and that being reminded of the work ahead is critical to this effort of making patient care safer, more just, and more transparent.
I watched the video again, took new notes, re-read those notes, and listened to the story and the discussion. I heard things I hadn’t heard before, heard perspectives that I hadn’t paid attention to in the past, learned new lessons, and was left with a re-galvanized commitment to this difficult, rewarding, and necessary work.
In the work that I do with healthcare leaders to change culture, I hear and see a lot of conversations, interactions and exchanges. Having the ability to reflect on what I have heard or seen, either from reading my own notes, re-remembering my experiences, or having the story interpreted by someone with a different perspective, provides me renewed energy, fresh insights and ideas about alternate solutions.
Day 1 reminded me that re-visiting the stories, notes, videos, conversations and perspectives are some of the most powerful reminders of the work still ahead to change the world of patient safety.
Thank you Helen for the reminder.
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
Culture and Love – a story from 2014
As 2014 drew to a close last week many a news outlet spent time reflecting back on the highs and the lows of the past year. Whether framed as a “top 10 list” or presented more as the best and the worst, here in northeastern Massachusetts one particular story caught my ear.
This was the Market Basket Story, a tale of unparalleled employee unity and pride, and living proof that a small group of committed people can in fact make a difference.
If you’re unfamiliar with this particular tale, there was a real cast of characters; long-time feuding, wealthy family members, unfairly (some would argue) fired senior executives, passionate, committed employees, and deeply loyal customers.
Bottom line: local grocery-store chain CEO fired by cousin (hate each other) board member, employees (loyal is an understatement) outraged and walk off the job, stand-off ensues, employees rally for the fired CEO to be reinstated, customers stay away at the request of employees (and there are no supplies on the shelves) and eventually the fired CEO buys enough shares to take control of the company and is reinstated – celebrations all around and bonus checks for employees!
The news story that I heard a few days ago was celebrating the fact that the entire body of employees has been recognized as the Boston Globe’s “2014 Business Person of the Year”, and reflecting on the leadership of Arthur T. Demoulas, the reinstated CEO, making the statement “… he was reinstated along with his culture of generosity, kindness and caring.”
I love this statement! His Culture!
Think about the words, his culture. This is not an abstract, difficult to grasp concept – this is his, the way he leads, the way he works.
In our work to improve safety in healthcare the word ‘culture’ gets tossed around all too easily. It’s easy to blame the culture, almost as if doing so excuses the behavior. It rolls off the tongue as part of our standard vernacular, and is often the response to much of what ails us:
Q: “Why are some of your operating rooms using surgical checklists and others not?”
A: “That’s just the way we do things here, it’s our culture…”
Q: “What stopped you from speaking up when you saw your senior colleague acting in that rude, disrespectful manner?”
A: “That’s the culture on this team, keep your mouth shut and your head down…”
It strikes me that we cite or state culture as the root-cause of the problem because it creates the impression that fixing or changing it is nigh on impossible. That to tackle, change or create a new culture is a myth so complicated that we best not even try…
The Market Basket story annihilates this myth.
Health and care leaders listen up
Culture is the way we act as leaders. It is the tone we set, the expectations we communicate, and the behavior, language and performance that we tolerate.
Culture is the way we (you and I) do things. Do you want a communicative, fair, safe culture? Then communicate openly about the good, the bad and the ugly. Be fair with the people that choose to work in your organization, and with the way you make decisions (don’t interpret as treating everyone the same…), and model an environment where speaking up about your mistakes and owning them is celebrated not frowned upon.
Remember, if it is to be it is up to me.
“His culture of generosity, caring and kindness.” The reporter goes on to interview Arthur T. (reinstated CEO) and he describes some additional tenets by which he runs his company, with fairness, justice, and connection to the human soul.
They’re running supermarkets people, and he’s talking about connecting to the human soul…
He nails it when he shares that the secret to this incredible story is to remember that they are, “… in the people business first, and the food business second.”
Health and care safety in 2015
People business first, medicine business second.
People is where our focus needs to be. Caring and healing our patients and their families, absolutely, it’s the calling that many of us responded to that finds us doing the work we do. But it needs to be more than this…
I propose that in 2015 we need our focus to be more on the people that provide this care – as leaders we need to make these people ‘the business that we are in.’ They will take care of their patients.
Commit to being in the people business first. The care givers; the nurses, the technicians, the physicians, the patient care attendants, the unit secretaries, the managers, the supervisors, the housekeepers, the pharmacists, the social workers and each other.
Provide the generosity, kindness, love, fairness and justice that connects them to their purpose, reminds them of their calling, and creates a safe environment for them to deliver the best care possible.
The reporter for the piece on Market Basket closed out the segment by suggesting that the Market Basket employee’s actions have presented other companies throughout the Commonwealth and around the world with a challenge of sorts – loyalty is one thing, these folks though clearly love where they work, and who they work for…
From loyalty to love!
Perhaps for 2016…
Yesterday afternoon the faculty and students at the “Telluride-East” Patient Safety Summer Camp visited Arlington National Cemetery.
As we paused for some reflections from our leaders Paul Levy and Dave Mayer I was overcome by the scale of what presented itself in the form of field upon field of white grave markers.
Poignant words reminded those gathered that we were indeed standing on hallowed ground and that many have given, and continue to give, the ultimate sacrifice. A sobering reality is that there are between 25 and 30 new burials every day at the cemetery.
Following our time of reflection I took a walk to reflect on the sacrifice, loss, and scale of what lay beneath me. 400,000 markers of lives once lived, now at rest.
In a recent piece of research published in the Journal of Patient Safety it is estimated that more than 400,000 hospital deaths are attributed to preventable harm. Put another way, since August 2013 more than 400,000 mothers, fathers, brothers, sisters, sons and daughters are no longer alive as a result of harm that could have been prevented with better designed systems, more situational awareness, and other proven human factors and safety science approaches in health care.
I think these numbers are becoming “noise” for many leaders in healthcare, we have heard the numbers and yet still choose not to make the different decisions and the difficult choices. We disassociate from the difficult reality because we don’t “see” the totality of what we are doing.
The grave markers stopped me in my tracks, a visual reminder of what we are doing every year in healthcare by tolerating variation, blaming people, doing the same things over and over and expecting different outcomes.
My walk took me to the Kennedy family grave site. Off to the side of the eternal flame is a Robert F. Kennedy quote that really resonated with the work we are doing with the faculty and students at Telluride-East:
It is from numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.
Robert F. Kennedy, South Africa, 1966
This quote captures what I will leave this time of learning and sharing with, and what I urge the students, residents and faculty to find the courage to continue doing…
- Lean in and keep speaking up to improve safety; these are the “numberless diverse acts of courage”
- Believe in yourself and the difference you can make
- Stand up for what you know is right and stand up for those less brave and courageous than yourself
- Speak up, even when your voice quivers and your hands shake. Speak up for patients, the ones you care for, know and for the one’s you dont…
- Most of all, send forth a “tiny ripple of hope”. These ripples will build to a current. These ripples will make care safer
- By thinking and acting differently, by bravely speaking up and taking a stand we will sweep down what often feels like a mighty wall
I commit to making ripples and I urge my new found colleagues and friends to do the same.
Make ripples. Ripples save lives, ripples make care safer.
I recently spent a day with a number of senior clinicians all working in an environment that is permitting pockets of disruptive, unprofessional, and quite frankly dangerous behavior amongst caregivers. The last conversation of the day ended with a chilling reminder that we still have much to do, “The problem is that for too long, to be successful in academic medicine, you haven’t needed to be polite, professional and well mannered…”
Last night I read a headline that really grabbed my attention…
Here was my reply:
I will start by saying that there is, in my mind, absolutely no place whatsoever for a disruptive (rude, hostile, ill-mannered, bad tempered) anyone in a safe, efficient, patient centered, healthy, just healthcare environment. Let’s not limit this to physicians…
I am sick and tired of hearing that being a technically excellent clinician and being a decent, respectful, polite human being are somehow mutually exclusive. They are not, and to suggest otherwise is disrespectful to the enormous number that are.
Please don’t suggest that organizations committed to improving the experience of those they serve are “getting rid of disruptive docs…” as an approach because they now have dollars tied to HCAHPS performance. This is a gross over simplification.
I’d offer that any healthcare organization that hires and retains mean, disruptive physicians (or anyone else) is complicit in creating a dangerous, un-just, unreliable work environment, not simply a less than ideal patient experience.
We need to start changing the conversation, raising our standards and expectations, and demanding more of one another. A world class, safe, reliable, effective experience is within our reach, but only if we stop confusing experience with “nice” and start holding ourselves and our colleagues to not only the highest technical standards but also high behavior standards.
I understand that we need to be mindful of the words we use, and am enthusiastically open to the idea that we need to lead with more “healthy innovative disruption” as we work to improve the safety and delivery of health and care. (Note the great work done by Helen Bevan and colleagues at the NHS with the notion of being a rebellious health and care change agent). But to suggest that disruptive behavior, in the way this article does, is somehow OK, and furthermore actually has a place in our healthcare environment, is reprehensible.
I’d love to hear your thoughts.
I am an optimistic person that believes that there are plethora hospital leaders doing the very difficult work of changing healthcare to make their cultures more effective, healthy, transparent, more reliable and less variable. I witness examples of these heroes every single day.
So before I take a little time to rant, let me explain… I work with healthcare leaders that are committed to learning from the past to improve the future, with data as their driver and compass. It is not easy work, per se (let’s be clear, it’s also not the front line care of patients), but it is work that I absolutely love! My reality is that what I do for work is a calling; and so my personal opinions are inherently woven into the work I do, I cannot unravel them.
I tell you this part as explanation, and part introduction; please know that I will never reveal the names of those I reference and would ask that your assumptions be kept to yourself. Needless to say, I think you’d be surprised…
I am sick and tired of the fact that I see many leaders in health care not being honest with themselves.
Unprofessional behavior is tolerated, expectations remain unclear, variation in practice is permitted, and human error is being allowed to harm patients; all the while telling people that they are the greatest, safest, most efficient healthcare system(s) in the world.
Why this lack of honesty? Is it that we’re afraid, or is it that we don’t know?
Do we not know the answers to safer more reliable, transparent, less costly care?
If we don’t know, are we embarrassed to admit that we lack the knowledge?
Are we afraid that if we stop supporting and promulgating the structures, systems, processes, excuses, and people that result in our current dangerous reality, that this will be an admission of past guilt? Are we afraid of the difficult conversations and actions that will be needed to lead a different organization?
I think it’s a combination of embarrassment, fear and a multitude of other deeply held attributes that many smart, well educated professionals have a difficult time “owning” and acting upon.
Let me be clear, I don’t think this is a knowledge gap. Other industries are way out in front of us with their use of technology, their speed to change long held approaches that no longer work, and their desire and ability to learn from others. Many hospitals have taken the lead and are modeling that you can hire for ‘fit’, support daily safety huddles and commit to a goal of “zero preventable harm”, just as a start.
I think we’re afraid of the reality that if we fess up to the fact that we have tolerated bad behavior, poor performance and mediocrity for so very long; that we will have to be vulnerable, naked, open to criticism, and honest with ourselves that yesterday we tolerated and did things that are no longer OK today…
So I have a challenge for myself and fellow healthcare leaders:
Start taking personal accountability for who and what your hospitals are. The good (great), the bad, and, the ugly. You are culture!
Own up to the fact that you know who your poor performers are…
Own up to the fact that you may not have articulated your expectations clearly…
Own up to the fact that there are voices of expertise within your organization that you are not listening to…
Own up to the fact that your hospitals culture is staring back at you from your bathroom mirror…
Own up to the fact that if you cannot state “zero preventable harm” as a goal – then, by definition, you have agreed to hurt someone’s loved one in a way that could have been prevented…
Own up to the fact that you got into this because you want to make a difference…
Own up to the fact that you’re tired, over worked, stressed, and that you don’t have all the answers…
Get out, go home, hang it up, retire! Your colleagues, caregivers, team, patients, community, all deserve better than your dishonesty.
We are surely complicit if we continue to stand by and watch – mute, deaf and blind.
I met with a senior member of a hospitals quality and safety department last week, he confided in me (after looking over his shoulder to make sure the door was closed) that his very reputable AMC doesn’t have the leadership “strength” to state that ‘zero preventable harm’ is their goal. He’s embarrassed and afraid to challenge his CEO.
I met with a senior management team that wanted me to know (after I’d found trash lying on the floor of their lobby, that they had walked past and ignored, and I suggested they ‘pick up trash’) that they “have people to do that…”
I hear leaders tell me that they know that their high revenue producing, senior position holding, research leading, long tenure physician colleagues are abusive bullies, and yet they are still employed, practicing and getting their annual bonuses…
These are choices, and my challenge is for us to make different choices.
My challenge comes with a promise…
My promise, is to keep asking difficult questions, pushing for the right answers, and encouraging and coaching healthcare leaders to be brave. Brave to ask when we don’t know, brave to admit that we made a mistake, and brave to reach out and request help.
I for one am not afraid. Apprehensive and nervous, for sure. Apprehensive that my comments will be seen as negative, accusatory and blaming, and nervous that this sentiment will be seen as one more heretic in the noisy world of working to improving safety and become more reliable and excellent.
But when I think about who we are harming, who we hurt every day in the spirit of “health” and “care”, I am not afraid. When I hear the stories of burned out, stressed, under resourced care giver friends and colleagues, I am not afraid. I’m buoyed, inspired and deeply moved by the memories of people like Michael Skolnik, Josie King, Lewis Blackman, and Jerod Loeb; people I never knew, but people who deserved so much better from the cultures that surrounded them and that were meant to take better care of them.
I am also encouraged and inspired by the health and care radicals (leaders at all levels of their organizations) that are making a difference and inspiring their colleagues to think differently, act differently, be transparent, have difficult conversations, model different behaviors and deliver on the promise of “Primum non nocere”.
So my promise is to keep asking difficult questions, pushing for the right answers, and encouraging and coaching healthcare leaders to be brave.
I leave you with challenges and inspirations from three very different healthcare leaders whose work I admire, and who model this mindset of personal accountability;
- “Rock the boat, without falling out” Helen Bevan (NHS guru of innovative change)
- “Ignite the fire within, not the fire underneath” Peter Fuda (Aussie based wicked smart PhD)
- “Proceed until apprehended…” Florence Nightingale