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?
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!
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Leadership lessons from training to run a marathon with my teenager.
I just finished read Richard Branson’s recent blog – Leadership Lessons Begin at Home. #thevirginway
Richard talks about watching and learning from the tenacious spirit, and limitless energy, of his mother Eve. I have a leadership lesson that I am currently learning at home, not from my mum, but from (and with) my seventeen-year-old son.
After running what I thought was my first and last marathon in 2004, my then seven-year old asked if we could run a marathon before he heads off for college. At the time I quickly agreed, and secretly hoped that he’d forget…
In the pre-dawn hours of a New England winter, the thought of running 26.2 miles was daunting, distant and in my opinion; impossible. So we crafted a plan and the lessons began…
Establish the goal
Run a marathon in seven months’ time… this was a stretch to say the least. After some discussion and research we got clear about our goal, and then both committed to it. Get to the start line injury free on October 12, 2014. We figured that if we could do that with all the necessary preparation and training, the running of the race, would be the icing on the cake. Clarity of expectations, getting on the same page, and clearly articulating the goal (with a date) was critical.
Change is personal
I hadn’t run for several years and I was carrying what my doctor referred to as “too much weight for my height”. Early efforts were small, and required changes to diet and a commitment to exercising at least four days a week. The lesson was that the changes necessary to achieve this goal were a personal choice, and not an easy one. If I was serious about achieving the goal I needed to stick to the plan and learn some new habits. We chose a different mind-set from the past to achieve the desired outcome in the future.
Break the plan down
Thinking about running for over four hours to finish a marathon, was incomprehensible at some level. The lesson here is that the biggest, most intimidating goal required a plan, an approach, and a way to eat the proverbial ‘elephant’. We used a spreadsheet to set out the miles that we would run for every single day until October 12, 2014. It became easy to understand, realistic to imagine, and allowed us to take every day one at a time.
We had a plan, we also had lives, and reality happens. The plan had us committed to specific miles that we needed to run every day, “long runs” on the weekends, cross-training days, and rest days.
My son is a senior in high school and I travel quite frequently for work. So we’ve had to get really good about communicating changes to the schedule, adjustments to the miles, and really good about sharing how each of us was feeling in any given week. We also found that communicating during the run was incredibly valuable. Asking for help, sharing what hurts and when, and being clear about our own needs made it easy to learn from each other and adjust the plan in real-time.
Achieving a different outcome (losing weight, running a marathon) has required different habits and choices. Early morning runs have had an impact on family, work, and school, and have required choices that have meant giving some things up. Fewer carbohydrates and fewer late nights are relatively easy sacrifices. The burden that training places on family has been a lesson in open communication, clarity of expectations and forgiveness…
Having a passion or a sense of purpose
Early in our commitment and decision, we decided to do the race in honor of my late mother, the grandmother that my son never met. We joined the team for the American Cancer Society. Knowing that our effort directly related to something that was bigger than us, that we have a passion for, and that we had a belief in, has buoyed us along the way.
Through five months of training we have learned that rest, relaxation and cross training (exercise that is not running) have been as important as the running. While the “work” has required discipline and a plan, so to have the activities that have kept us “whole” as people. This focus on our resiliency has ensured that we have enjoyed this experience, and has set us up to be the best that we can be. Taking care of ourselves and those we work with as whole human beings is something that I am now, more than ever, astutely aware of.
There are other lessons that I continue to learn from my running partner and my all too soon “off to college” son. The lessons of tenacity, perseverance, hard work, sacrifice, good humor at all times, listening, laughing, tradition, and family, to name a few.
Rudyard Kipling’s final sentence of “If” captures some of this sentiment for me:
“If you can fill the unforgiving minute with 60 seconds worth of distance, run, yours is the earth and everything that’s in it, and — which is more — you’ll be a man, my son”
Every time we lace up, stretch out, and get ready to run, I realize that we are also creating special memories that will stay with us both for many years to come. Thanks for the lessons my son, I’ve loved every mile of them. I love you!
24 days; 20 hours and 31 minutes to the start line! We’ve got this!
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
Paul Levy very kindly posted a video on his blog “Not Running a Hospital” that was prepared by the Beryl Institute. I have enjoyed the perspectives, feedback, and conversation that this has generated. Thanks Paul and thank you to Jason Wolf and colleagues at the Beryl Institute.
Some of the feedback I have received got me noodling a question that a friend and I grappled with over lunch last week. My friend and I share a background in the hotel business, and find ourselves having similar conversations on an increasingly frequent basis…
Why is it that when it is suggested that we look outside of the broken, over-worked, stressed, highly unreliable and wildly expensive system that we call healthcare (btw; the ultimate oxymoron), that we so quickly find all the ways that we are “different” from every other industry or business.
Even within healthcare we rush to say how different we are from one another. “…our patients are sicker, our payor mix is different, and our population is more expensive to care for…”
We really have to stop doing this, because quite fankly it”s not true. In fact, I’ll go as far as saying that I believe we’re lying to oursleves. I challenge us to contemplate what “yes” might look like, before we rush to “no”. How we’ve always done what we have always done, is clearly not working…
There is much to learn, and there are many willing to share.
There are a growing number of examples where hospitals, health systems, and their leaders (Dave Mayer MD at MedStar), that have embraced some of these concepts, have started a daily (EVERY day) “pre meal”… (“safety huddle” is the term we’d use in a hospital), have begun to put a line in the sand and “not blink” in regard to poor, unprofessional behavior, and have begun to learn and improve in similar ways as the military, aviation, nuclear power plants, and yes, in similar ways as many hotels…
And we’re just scratching the surface.
Many of the faculty and students at this year’s Telluride Patient Safety Summer Camp Roundtable took part in a hike up to Bear Creek Falls this morning. A stunning visual reminder of the majestic beauty that is this part of the country. The hike began with us all meeting in the town of Telluride and we walked over the river and into the woods.
At the trailhead was signage welcoming hikers to the trail, and providing insights and facts to parts of the hike to the water fall. Each numbered narrative entry corresponded to a part of the map further along the trail – number 1 corresponded to the spot where we were standing – it was a note of welcome, orientation and reiteration of the good citizen expectations.
14: Bear Creek Falls
Just stand there, beneath the Falls. The splendor needs no words: You simply belong.
Fortunately, we can continue to belong because local people have taken pragmatic steps and personal responsibility to purchase and restore Bear Creek as public open space.
Look around where you live and notice what is happening. It may be painful. If it is, don’t just forget and regret. Your acts of stewardship can truly matter. They have in Bear Creek.
As we completed the hike, enter into the final day of this incredible opportunity for honest, brave conversation around improving patient safety, and now ready ourselves to return home; I thought that ‘Bear Creek Falls #14’ can also applies to each of us:
Safe, transparent, compassionate care
Just stand there, with the stories of harm, loss, fear, hope, and encouragement. The reality needs no words: You simply belong.
Fortunately, we can continue to do this work because people have come before you, continue to lead, continue to learn, and have taken pragmatic steps and personal responsibility to lean in and restore safe, patient-centric care as a human right.
Look around where you work and notice what is happening. It may be painful.
If it is, don’t just forget and regret. Your brave acts of compassion, leadership, collaboration and transparency can truly matter. They have for all those that have come before you, and will for those that follow in your footsteps.
“The future belongs to those who believe in the beauty of their dreams…”
With each passing hour I am reminded how blessed, humbled and fortunate I am to be a part of this year’s Telluride Patient Safety Summer Camp Roundtable. The setting up here in the mountains is surely beautiful, and so are the dreams, honesty, transparency and truthfulness of the students and their faculty.
With each presentation, discussion, break-out, game, meal, and conversation I am struck by the honesty and openness of the future of healthcare.
We cannot expect to envision and lead a truly safe healthcare culture unless we are willing to dream, and then share those dreams. For these are the dreams of transparent, trusting, patient and caregiver centered, and compassionate care.
I have already learned so much from the students and faculty here in this beautiful place, please keep telling your brave stories, be brave enough to share your dreams, and be brave enough to embrace that you are culture, and your dreams are an inspiration.
Our language, the words we use when we use them, our inflection, emphasis, and our body language are all critical elements of building and leading a safe culture – so too are the feedback loops necessary to keep us honest.
I recently read the transcript of Don Berwick’s 2010 Yale Medical School graduation speech as case study preparation for this year’s Patient Safety Summer Camp in Telluride. One of the most poignant aspects of his speech for me, is the reminder of the power of the words we choose. Don reflects on a patient’s wife hearing the word ‘visitor’ as a label to identify her when visiting her sick husband. Don asks us to reconsider this, to change our mindsets, to think differently.
Don invites us to make a personally accountable choice to consider that it is us, physicians, nurses, housekeepers, technicians, the entire care team – that are in fact the real ‘visitors’ in the lives of those we care for. Think about it – the husband, wife, partner, lover, friend, child, sibling they are the relationships, the rocks, the memories and also, in many cases, the caregivers. Think about how they want to spend time with their dying or sick family member, what do they need? What do they want to talk about? We must remember that we are indeed the visitors in the lives that we are fortunate enough to care for.
The students and faculty at this year’s roundtable have been using different words, and have been open to hearing feedback regarding their mindsets around language and the words they use. I spoke at a recent company meeting about feedback and how we can choose to think of it as either a tennis ball or gift. If the former, it comes at us fast, it could hurt, and we are naturally inclined to want to immediately hit it back. Thinking of feedback as a gift changes our perspective–if done right it’s packaged well, we can take it with us and open it when we want, and it’s ours to do with as we please (keep or discard…)
Watching the #TPSER10 faculty modeling openness to feedback and hearing the tough messages, and hearing the students give and ask for feedback is eye-opening and refreshing. John Nance reminded us that some element of communication failure is behind almost every sentinel event and serious safety event.
Our language, our words, our ability to ask for and receive feedback help us communicate better. Ask for feedback about your language and the words you are using, and then keep the gift…
The show-stopping line from the Hans Christian Anderson’s 1837 fairy-tale is actually, “But he has nothing on!”
A brave, young, clear thinking boy in the crowd is the only person confident enough to say what he thinks and speak up. Perhaps even more simply, the young voice in the crowd has not had the life experience that often builds (and rewards) the filters of loyalty, flattery and only saying and thinking what we think others want to hear.
The story resonates so much that it has been re-told and re-written in as many different languages as cultures. In Denmark it was The Emperor’s New Clothes, in Sri Lanka it was crafted into The Invisible Silk Robe, in Turkey the story is told as The King’s New Turban, in India, as The King and the Clever Girl and in my homeland, England, we grew up with The Miller and The Golden Thumb.
The languages, settings and details differ; the moral remains the same and is well known, that we shouldn’t believe everything we’re told, especially if the evidence doesn’t support the claim.
Some will tell us that an additional lesson was about making a fool and mockery of the Emperor, but, in fact, he clearly does that to himself. He was a fool for not believing what he knew to be true, which can lead us to conclude that he took his position as Emperor for granted, especially in his belief that as Emperor no one would ever lie to him.
The analogies to our hospitals, departments and clinics are clear and prompt some important questions:
- Have we created an environment that promotes or inhibits speaking up?
- Have we become so confident and conceited due to our names and rank that we sometimes don’t acknowledge what we know is true?
- Are we ignoring what the data is telling us for fear of embarrassment?
- Are we doing something just because it’s the way the “crowd” does it, or the way we have always done it?
- Are we willing, as leaders, to take the risks required to speak up and act differently? (to be that little voice in the crowd)
- What are the risks associated with speaking and acting differently?
By any report, our hospitals, healthcare systems and practices are still unsafe and not as patient and family centered as they could be. As leaders of these organizations we must be willing to take, and reward, the risks associated with speaking up, with acting differently, with finding alternate solutions.
The risk of not doing this is too great – it’s more of the same.