Language and Hierarchy

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.

 

 

 

 

 

 

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Critical Reminders from Day 1

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.


Pecha Kucha comes to IHI 26 Forum

Pecha Kucha!

“Bless you!” were the first words out of my mouth when I heard someone say peachakoocha during this week’s 26th annual Institute for Healthcare Improvement (IHI) Forum in Orlando, FL. On hearing the word, my 12-year-old daughter thinks it sounds like the name of a Pokemon character…

Weird word = wonderful experience
In a conference environment that can be all too often filled with long-winded PowerPoint presentations with presenters reading slides, this was an energizing and welcome change.801t

“PEHcha KOO-cha,’’ is the English pronunciation, of what appears to be a rough translation of the Japanese word(s) for “chit chat’’. Picture an event akin to a poetry slam. A Pecha Kucha is where subject matter experts get together to share their work, opinions and beliefs, and get to hear from others. A fast paced opportunity to share, learn and be inspired.

Pecha Kucha started in 2003 in Tokyo and has since migrated to almost every country in the world. Originally designed to share ideas in design, architecture and photography, it has apparently now come to healthcare. There are now Pecha Kucha ‘nights’ in more than 300 cities around the world.

How does this work?

The Pecha Kucha at this weeks IHI meeting was hosted by Helen Bevan, Chief Transformation Officer for NHS Horizons Group (UK) who acted as host and ‘race marshal’. She explained to the audience what would happen, then welcomed each presenter to the podium, and then asked, “are you ready?”, setting their slides running for the ensuing sub seven minute presentation (6 minutes, 40 seconds)…640

Presenters — there were 8 of them at the IHI — shared and narrated 20 slides for 20 seconds that “auto-ran”, meaning the presenter had no control over slide advancement, the slides roll…

The 20 x 20 format is at the core of a Pecha Kucha. The emphasis here is on speed! Can’t keep up, then you’re likely not ready for this rapid fire onslaught of ideas and inspiration.Pecha Kucha 2014

What we witnessed at the IHI Forum was a Pecha Kucha focused on the theme of “my hope for the future of healthcare”. These were inspiring stories of why each presenter had been called to make a difference in healthcare and provided insights into specific projects that each of them were working on. Beautifully inspiring, brave, personal stories of commitments to lean in and make health and care safer, more accessible and more relationship driven; the triple aim is alive, well and thriving!

A refreshing change at a terrific conference. I commend Helen for leading this and congratulate the IHI for welcoming this imitation of a clearly different approach to sharing, learning and inspiring.

I’m a Pecha Kucha fan!

pechakucha2nobanner

Check out this Pecha Kucha Storify


Personal Accountability

A conversation with Chuck Lauer

Last year I had the wonderful opportunity to be introduced to Chuck Lauer, the former publisher of Modern Healthcare, by my good friend and colleague Kristi Peterson. Chuck and I spent considerable time talking and emailing about a subject of mutual interest and something we are both passionate about, accountability, specifically about the idea and concept of ‘personal accountability’.

This concept of personal accountability, and the choice to change the words I use when I think about accountability, are in part lessons from the leadership, writings, and friendship of Linda Galindo.

Chuck went on to pen a piece that appeared in Beckers Hospital Review on August 17th 2013. I just re-read it, and thought I’d share it here again. Enjoy…

We hear a lot about “accountability” in healthcare — from the boardroom, to the workplace, to new payment methodologies like “accountable care organizations” — but most people don’t have a clue about what the word really means.

Everyone knows the basic definition: Accountability is a kind of answerability. The word derives from having to give an account — to clearly explain what you are doing. But the actual definition goes much deeper than that.

Richard Corder, assistant vice president of CRICO, a Harvard-affiliated malpractice and patient safety organization, has thought a lot about what accountability is — including what it is not. It is not, he told me recently in an email, about saying “yes” whenever your approval is sought. “In healthcare, we have fallen for the belief that good service means saying yes to everything,” he said to me. “Saying no — and being clear about why, and when you may be able to meet, chat, review, discuss — is a liberating, time-saving, accountable action.”

One of the things often missing in today’s workplace, he said, is a lack of clarity about what accountability really means. “Treating everyone the same is disrespectful to our high performers and excuses (rewards) our middle and low performers,” he said. Fairness is not about treating everyone the same. As leaders, we understand that we have to treat, manage, coach and lead people differently — based upon performance and needs.

“In healthcare, we are currently spending a lot of time (and money) talking about and pondering the ‘accountable entity,'” he told me. “We wax and wane poetically about the who, what, why, when and where, when all the time it’s staring back from the mirror. We are the accountable entities.”

That gets us to the heart of the matter: Accountability has to start with you! If you are ever going to be successful and fulfilled in your life, you have to be accountable to yourself. Sure, you can kid yourself about how good you are, and you can even fool other people by what you say and how you behave. But do not forget that the hardest person to satisfy is you! You have to judge yourself and live with it every day!

Each of us is an accountable entity. That’s why, when leaders lead with clarity and conviction, honesty and transparency, they bring with them inspiration and determination. They have become accountable to themselves! It’s a contagious enthusiasm that permeates their organizations. Talented people are attracted to institutions where leaders are dedicated to innovation, creativity and risk-taking. They fully accept that answering to oneself is the key to success.

I have had the honor of meeting a lot of great people — people who have made a difference and achieved unparalleled success in sports, business and other pursuits. None of them really caught fire until they took stock of themselves and became accountable. Some did this when they were young. Others didn’t face up to themselves until they were older. But in all cases they look back and say that being accountable to themselves is what changed their lives.

Richard Corder said personal accountability means always trying to be clear. When confronted with a problem, you can say, “I tried, but they wouldn’t let me,” he said, or you can say, “Can you help me figure this out? I need to get some clarity.”

It’s important to put some effort into establishing clarity, he said, offering me a quote from the inspirational speaker, Mark Victor Hansen: “By recording your dreams and goals on paper, you set in motion the process of becoming the person you most want to be.”

Listening to yourself can help you put your plan into action. I don’t know about you, but I have conversations with myself all the time, and from what I can gather from colleagues and friends, they do the same thing. This enables us to begin to develop a sense of our own accountability.

With accountability comes additional responsibility. For instance, in your job, do you speak up when you feel something could be improved? Or are you so concerned about the risk of falling out of favor that you don’t say anything?

In healthcare, we too often delude ourselves into accepting the status quo and are unwilling to try new things that just may be more efficient and guarantee a better experience for the patient. Accountability has to start with people who are willing to hold themselves to a higher standard and be answerable to themselves at all times. The goal is to never deviate from your dedication to excellence.

The road ahead is paved with uncertainty, and you will probably have to drive over many potholes along the way. The whole industry needs leaders who have the courage to look into the future with clear eyes and to inspire their people to do the same. We need to be willing to bring about the changes that healthcare so critically needs. It isn’t going to be easy. Those who hold themselves personally accountable to mission and vision and to themselves will be the stars that inspire all of us with their courage.

Richard Corder gave me a kind of motto for personal accountability. It’s all simple, two-letter words that go like this: “If it is to be, it is up to me.”

I have already put them up on my office wall.

 

Thanks again Chuck for the friendship, mentorship, interest, and support.


Lessons from the road

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…

Running 1So here we are ten years later, his memory is top-notch, and we are now less than four weeks away from running his first (and maybe my last) marathon…

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.

Running 3Communication

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.

Sacrifices

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.

Resiliency

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.

 Running 2There 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!

 


Numberless diverse acts of courage

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.

 

Arlington 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:

 JFK Quote

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.

 


You promote what you permit

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…

Why disruptive docs may not be so bad after all

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.