It’s been more than five years since I dipped my toe into the world of blogging when I wrote – “The Emperor is Naked! Taking risks to reduce risk…”
The title was a clumsy headline intended to grab your attention.
The point then is the same as it is today so here’s a reprise – Still Naked
The fear of speaking up and being vulnerable is getting in the way of delivering safe and effective healthcare. The fear of speaking up is paralyzing leaders and their teams.
Coming over that fear requires bravery and as my friend and mentor Steve Farber (author of the Radical Leap) would say, vulnerability:
“Vulnerability aids human connection, and connection is the conduit for energy. Pretense of invincibility builds walls and creates distance between human hearts.”
Time to close this distance. Time to speak up. Time to get naked…
“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
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.
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
As we closed the daylong exchange from some of the country’s leading minds on safety culture, I wanted to recap the themes that we heard and that seemed universal across the day’s conversations. Here’s what we learned and how we captured the “lessons”:
- You are your culture. What you say, how you model, how you behave and what you tolerate is culture. You are personally accountable.
- Open up to the fact that there is only one kind of empowerment. Self-empowerment. No one can “give you” empowerment. You can be given authority. Self-empowerment—take the risks, “lean in”, and get the results that you desire.
- Assess your current reality. Where are you at? Where is the company at? Where is your team at? Are you where you want to be? Look in the mirror, under the covers, and be honest with what you see.
- Hire and retain those that share your company values. Make the difficult decisions on those that don’t fit. Use data. Be brave.
- If you’re about to say “no” to an idea, an approach, an alternate, or a different way of doing things. Stop! Consider what “yes” would look like. You do have a choice.
- Support, reward, recognize, celebrate, and listen to your employees. Period.
- Talk to people, not about them. Eliminate gossip—it is killing your culture.
- Tell stories. Invite everyone to share their narrative.
- Keep doing the difficult, heavy, awkward, challenging, rewarding work that is changing the culture of healthcare. Your patients, their families, your colleagues, and the children in your lives are relying on you.
Thank you for all you do every day to improve.
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.