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?
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.
“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.
“PEH–cha 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)…
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.
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!
Check out this Pecha Kucha Storify
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 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
Last month, at CRICO, we hosted healthcare leaders from around the country at our annual patient safety symposium “Walk This Way”. My talented colleague and dear friend, Dana Siegal, RN, CPHRM, opened up the meeting with a theatrically inspired look back over her career as a registered nurse, and patient safety expert. Reflecting through narrative and performance that we (healthcare) have come a long way with regard to our tolerance/acceptance of smoking in the workplace…
Now, if that’s all you were left with, you missed her point! She deftly wove the analogy of smoking in with many other “journeys” of change, from seat-belts to car seats, from drunk driving to exposure to sunshine safety. Up to and including our current journey of patient safety; from pre-IOM report, through “Crossing the Quality Chasm”, up to and including the most recent Lucian Leape white papers.
With this as a back drop, Dana challenged us with a hopeful message, that indeed journey’s such as these take time, require leadership and demand that we stay focused. We explored how attitudes, policies, and behaviors—that is, the workplace culture— related to smoking changes over time. We looked back in amazement to a time when physicians, nurses, and patients openly smoked cigarettes in hospitals and other health care settings…
Then we asked our Walk This Way attendees to place themselves 10 years into the future, and make a prediction about changes related to patient safety in their workplace that would make the look back in amazement…
It’s hard to believe that back in 2014 we:
- Worried that all clinicians were not reporting adverse events or near misses or good catches
- Took over a year to build a patient portal while arguing about what to “allow” patients to see
- Shouted at colleagues while treating patients when something went wrong
- Sequestered doctors and nurses from other health care workers
- Kept adverse events a secret from staff
- Expected patients to make their own appointments for consults and follow-ups
- Blamed people working in bad systems versus looking at the process and making that better
It’s hard to believe that back in 2014 we didn’t:
- Allow patients full access to all parts of their medical record so that they can truly partner with us in their care
- Always wash our hands when seeing patients
- Feel comfortable stopping the line when something doesn’t seem right
- Have a standardized handoff process
- Have efficient systems for formally tracking/following up on abnormal test results
- Respond effectively to every instance of disrespectful behavior
- Round on patients as an interdisciplinary team
By definition, this is our “current state”…
What will you look back on in 2024 and be “amazed” that we did or didn’t do?
Does it need to take us ten years?
“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.
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.