Tuesday, May 28, 2013

Tip 21: When patients are in the line of fire


Is incivility causing your organization to be less compassionate? And what impact does it have on safety and overall patient experience?

A recent Harvard Business Review article titled, The Price of Incivility, by Christine Porath and Christine Pearson suggests rudeness at work is on the rise, and their findings are quite consistent with what we see in the organizations who call us for help.

Over the past 14 years Porath and Pearson polled thousands of workers about how they're treated on the job, and 98% have reported experiencing uncivil behavior. In 2011, half said they were treated rudely at least once a week—up a quarter since 1998. We can only conclude that these uncivil behaviors, exchanges and experiences are chipping away at our organizations' ability to prevent harm, improve quality and build trust in our communities. The authors point out that most managers believe incivility is harmful, but many leaders do not recognize the widespread affects and tangible costs. The authors' research of 800 managers and employees in 17 industries including healthcare, demonstrate the widespread effects of these actions. Among workers who've been on the receiving end of incivility:

  • 12% said that they left their job because of the uncivil treatment.
  • 38% intentionally decreased the quality of their work.
  • 47% intentionally decreased the time spent at work.
  • 48% intentionally decreased their work effort.
  • 63% lost work time avoiding the offender.
  • 66% said that their performance declined.
  • 78% said that their commitment to the organization declined.
  • 80% lost work time worrying about the incident.

Arguably the most concerning finding for our industry might be that 25% of respondents admitted to taking their frustration out on customers. It goes without saying that our organization's culture has a tremendous influence on improving safety. These are just a few of the challenges we must begin giving more attention to as an industry if we are to get a a better handle on preventable patient harm.

The authors interviewed employees, managers, HR executives, presidents, and CEOs. They administered questionnaires, ran experiments, led workshops, and spoke with doctors, lawyers, judges, law enforcement officers, architects, engineers, consultants, and coaches about how they've faced and handled incivility. They collected data from more than 14,000 people throughout the United States and Canada in order to track the prevalence, types, causes, costs, and cures of incivility at work. They concluded two things: Incivility is expensive, and few organizations recognize or take action to curtail it.

Let's remind ourselves that incivility doesn't have to be a mad surgeon throwing a scalpel in the OR to harm the patient, but a simple rude comment that creates the conditions for one staff member to avoid the other, impairing communication and setting the stage for patient harm.

While this article offers a number of valuable findings on incivility and the effect disruptive cultures have on organizational performance, I wanted to concentrate on one specific finding we are all to familiar with. The authors share that only 11% of organizations report considering civility at all during the hiring process, and many of those only investigate it in a cursory fashion. These findings are consistent with our experiences working with healthcare systems across the country. The good news for our patients on the receiving end, is that we are starting to see more organizations connecting the dots... recognizing just how much collateral damage and patient harm can occur when we don't hire the right folks. Many organizations neglect to see hiring and recruitment as the first line of defense in their patient safety infrastructure.

The authors share that incivility leaves a trail of some sort, which can be uncovered if someone's willing to look. Here's one example, "One hospital had a near miss when bringing on a new radiologist. It offered the job to Dirk, a talented doctor who came highly recommended by his peers and had aced his interviews. But one assistant in the department had a hunch that something was off. Through a network of personal contacts, she learned that Dirk had left a number of badly treated subordinates in his wake—information that would never have surfaced from his CV. So the department head nixed the hire. Dirk doesn't realize the impact his behavior is having on patients and it's one that I illustrate in my upcoming book, Heroes Need Not Apply: How to build a patient accountable culture without adding more to your plate, where a Dr. Hartley, an oncologist makes a few harmful comments that wind up creating a trail of destruction for one of his patients: His incivil behavior toward his transcriptionist resulted in his surgical notes being incorrect, which ultimately led to the death of a patient. He instilled such fear that his transcriptionist threw in the towel and guessed on one word... which happened to be the difference between life and death.

CL Tip 21: Civility: Screen for it and coach with it

What happens when you leave aligning what matters most to our patients and culture to chance? We get an organization that is less likely to be compassionate with the increased risk of incivility.

Porath and Pearson share, "We're always amazed by how many managers and employees tell us that they don't understand what it means to be civil. One quarter of the offenders we surveyed said that they didn't recognize their own behavior as uncivil."

But why is there such a disconnect in healthcare where compassionate people come to work? We are an industry that has a long history of rewarding the T.E.D. attributes (see image on left), and neglecting the human side of our business... the actions and behaviors that matter most to patients (T.R.U.S.). If you've been in healthcare long enough, you've been exposed to a number of living examples and products of healthcare culture. You know, the talented, well trained nurse/doctor/leaders who get the results, but don't play well with others. They seem to create a "windchill effect" when they come into the room as they are often disrespectful and unapproachable. They don't recognize the effect they have on their staff and/or colleagues and how their tone starts a chain reaction that put's the patient's life on the line. The article describes how targets of incivility often punish their offenders and the organization, suggesting that most hide or bury their feelings and don't necessarily think of their actions as revenge. For a moment, consider how this cycle can and does impact our patients? This is a critical problem that doesn't need initiatives or huge budgets to repair. As someone wise once told me, "I'd rather have someone nice and teach them to be smart than have someone smart and teach them to be nice."

Email me or share your thoughts on our Facebook page.

Tuesday, May 14, 2013

Tip 20: Leaders think small to improve safety

Leaders think small to improve safety

Bobby KnightIn our overly complex world of Healthcare there is something to be said for thinking small when searching for the right solution to a complex problem like safety. Don't underestimate the genius of small ideas and actions. These little things often surprise us by generating subtle but substantial change that leads to amazing results. From time to time I'm reminded of the light hearted side of the theme: the famous "Think Small" Volkswagen Beetle ad campaign that came out in the 1950's, Steve Martin's album "Let's get small" in 1977...certainly worth listening to if you haven't heard it in awhile. The reality is that there is true value in "thinking small" if you're a leader and/or physician looking to help your staff have a greater impact on improving patient safety.

I was reminded of the concept in a recent article in the New Yorker that tracked the origin of Earth Day. Today, we all know Earth Day as a global movement that led to the Clean Air Act of 1970, the Clean Water Act of 1972, the Endangered Species Act of 1973, and just eight months after the inaugural event, the establishment of the Environmental Protection Agency. Throughout the seventies, Congress passed one environmental bill after another, establishing national controls on air and water pollution. Most of the powerful environmental groups we know today are by-products of the Earth Day movement. Many of colleges and universities instituted environmental studies programs, and many news agencies became dedicated to regular reporting on environmental issues. Earth Day is just one of many examples of how movements that led to great change didn't require highly coordinated efforts. Quite the opposite really, and in the case of Earth Day, those closest to the movement will tell you that it was largely uncoordinated. The rapid success of the movement took it's champions by storm, captured the hearts and minds of millions, and has contributed to small changes in behavior across the globe that made a substantial difference.

So how can the Earth Day movement help inform healthcare leaders on how to have a greater impact at improving patient safety?

It helps us to realize that as leaders a handful of small actions can lead to big results. Improving safety doesn't always require a well coordinated movement or major organizational initiative. We don't need to wait for the board or medical staff consensus to authorize new initiatives to achieve the patient safety outcomes we keep talking about. Many of the organizations we work with have done an outstanding job improving safety, but often discover that all the checklists and initiatives in the world only get you so far. Your future gains in reducing harm and improving safety will need to come from a different place. As the coach of your team who understands that small insights and actions will contribute greatly to safer conditions can also lead to a movement that even surprises you.

CL Tip 20: The Power of Small

Recently, I've been asked to do several interviews to discuss my upcoming book Heroes Need Not Apply: How to build a patient accountable culture without adding more to your plate. I am asked regularly why a doctor would be anti-hero? I keep reminding people that I'm not anti-hero....just anti-heroic effort. Heroic effort certainly did not make the Earth Day movement a great success and it's certainly not going to be the driving force for making patients safer. The hero mindset in healthcare has minimized teamwork and has led to cultures that generate episodic excellence. That sounds a bit unpredictable if you're the patient. The only way to achieve systematic excellence is through small behaviors and actions that reinforce collaboration, matter most to our patients, and create safer conditions.

I've been listening to your feedback, I understand that most leaders in healthcare realize the value in coaching their staff. The concern is where to start and how to find the time?

As we've pointed out in prior issues, introducing coaching into your leadership practice doesn't require more to do, but often provides leaders tools that result in time saved. One of the benefits of incorporating coaching into your leadership practice is that it offers more frequent opportunities to guide staff, build team trust and strengthen relationships. More frequent interactions with staff doesn't translate into more time leading... as the leaders I work with report significant time saved due to less upward delegation and more effective/shorter meetings. Coaching isn't something you do every 6 months at a performance review and it doesn't need to take place in a private room with comfortable seats and subtle lighting, nor does it need to take hours like some leadership approaches we know.  Keeping with our theme of small actions - big results, this tip might be one of the most effective and underutilized skill leaders practice:

Use silence effectively to allow others to think.

While the idea of using silence as a coaching tool could be perceived by some as a whole lot of nothing, the most effective leaders we know in and out of healthcare apply it to every conversation. Just the word "silence" suggests passive behavior, but we've found it to be anything but. As a physician, I discovered the benefits of using silence or what I often refer to as "creating space" so that my patients have the opportunity to tell their story. As providers we have grown fearful that if we offer space in the conversation for our patients to ask a question or share a thought, they'll ask for more than we can give...simply not the case. The opposite is true. When you offer patients and/or staff the opportunity to think by creating space, you create an opportunity for listening to occur and an insight to be made. When your staff/patient is aware that you listened to them, they feel safer, they are more likely to trust in your leadership, and engage in the change you're advocating.

Creating space might look and feel like a small thing, but the safe exchanges it creates have a remarkable impact on improving care. Effective coaches know that every conversation they engage in can offer perspective and insight... all you have to do is pause from time to time.

Email me or share your thoughts on our Facebook page.

Brian WongDr. Brian Wong's highly anticipated book,'HEROES NEED NOT APPLY' releases this spring.

Listen to Dr. Wong as he discusses Heroes Need Not Apply: A Unique View on Accountable Culture Click here to listen>>

Brian WongCheck out the new video interview with Brian Wong, M.D.
to access Dr. Wong's Q&A as he discusses "Heroes Need Not Apply," Click here>>

Thursday, May 2, 2013

Tip 19: Coaching: The path to patient safety

Coaching: The path to patient safety

Bobby KnightIn our last issue we discussed how to navigate medical hierarchy in the most difficult of circumstances and shared a proven coaching tool for defusing potentially harmful conversations among physicians. The safety challenges that medical hierarchies present are no surprise to the physicians at the Bedside Trust. What is surprising to them and most of us, was just how effective a question like "what matters most to our patient this moment?", could be at disarming unsafe exchanges among providers. One reader commented, "You know... it's one thing to sit in the boardroom and discuss putting the patient in the center, and it's another to have physicians asking each other the same questions at the bedside where it really counts." In her recent New Your Times article, "Afraid to Speak Up to Medical Power", Pauline Chen, MD discussed her personal experience in dealing with the all too common unsafe medical hierarchy that is endemic of our current healthcare culture. I'm glad to see such well respected physicians confronting these "old rules" that have such a profound impact on patient safety.

But what's keeping patients from consistently experiencing the benefits of physician coaching every time unsafe exchanges arise? I use the term "physician coaching, not just because it's more relevant to physicians than the concept of leadership, but because coaching offers the tools that keep patients safe. Chances are you have heard talk about having a coaching culture or a coaching style of management.

A client recently sent me Atul Gawande's article Personal Best, published in The New Yorker September, 2011. Gawande makes the general case for coaching by offering this statement " No matter how well trained people are, few can sustain their best performance on their own. That's where coaching comes in." He also pointed to a limitation of coaching saying, "The concept of a coach is slippery." The concept of coaching is slippery because it lacks definition in most organizations. Coaching is one of those concepts where definitions vary according to who you ask. Can you think of other terms in healthcare that are hard to grasp: patient-centered, leadership, physician leadership (if you really want to confuse physicians), even the concept of accountability and culture requires context to truly understand the concept. 
When I first begin to talk about coaching to most leaders in healthcare they immediately think of the context of a sports coach. As spectators, the camera often pans to the angry coach on the sidelines yelling orders to his players. You might categorize this best as a directive style of coaching. For those leaders that feel the need to show authority, the non-directive style can appear soft or weak. And yes, telling people what to do is often perceived as quicker and more effective on the field or in the ED, but only in the very short-term. In other words, if you're a coach of a professional football team or a physician needing to improve the performance of your ED staff, you'll recognize that directive styles have considerable limitations long-term. If we are going to achieve sustained excellence in patient safety, we healthcare leaders need to practice and emphasize our long-game coaching tools.

Tip19: A culture that rewards and recognizes coaching is a safe culture.

Coaching can involve a range of styles and techniques with a directive approach at one end of the spectrum and non-directive at the other. If a first year ER resident is learning a new technique for intubating a patient and has no idea what he is doing, then clearly the Resident needs to be given instructions and shown what to do, requiring a directive approach.

Even in healthcare, which can often feel like the ultimate sport, leaders and physicians have ample opportunities to offer non-directive coaching to staff. Take a very well trained nurse manager who may be experiencing a period of less than stellar patient satisfaction results.This person has the skills to do her job, so taking more of a non-directive approach to improve performance may be required. While a directive approach relies heavily on giving answers, non-directive coaching emphasizes questions designed to get the team member to explore previous experience for solutions. Listening and properly reinforcing their confidence and ability is more likely to get the engagement required for the results you expect.

Non-directive coaching tools can be very effective for the development of people and when behavior change is required. And I don't have to remind you that these are the issues that most challenge leaders and cause harm to patients. For example, if someone is unsure about a decision they need to make or how to handle a problem, is just giving them your answer the most effective way of teaching? I suppose if the decision was urgent as in some healthcare situations, then maybe you would have to. However, if it wasn't, for improved personal development, you could ask them what they would do and get them to think of other options?

Look no further than the all too familiar example provided in our last Coach+Leader. Two physicians, one afraid to approach the other, due to the unsafe conditions created by medical hierarchies. In many of the cases we see, the physician has ample time but fails to act simply due to the fact that the medical staff does not emphasize coaching as a core component of it's culture. Open ended questions like the one we shared are perfect coaching tools to combat medical hierarchies as they redirect the physicians in question to focus on what matters most to our patients, rather than trying to determine the smartest person in the room.

If you're a leader, a physician, or in a management position, you are in the right place to start thinking like a coach. In the case of coaching, there needs to be a top down approach, because leaders have the most impact on building a Patient Accountable Culture. As healthcare leaders, coaching must be viewed as a primary tool not just for improving team performance, but for improving patient safety. Our patients expect us to work as teams... patient-centered teams need coaches, and every leader has a coaching role.

Stay tuned to Coach+Leader as we continue to build the case for how leaders and patients benefit from organizations that make coaching a priority.

Email me or share your thoughts on our Facebook page.

Brian WongDr. Brian Wong's highly anticipated book,'HEROES NEED NOT APPLY' releases this spring.

Listen to Dr. Wong as he discusses Heroes Need Not Apply: A Unique View on Accountable Culture Click here to listen>>

Brian WongCheck out the new video interview with Brian Wong, M.D.
to access Dr. Wong's Q&A as he discusses "Heroes Need Not Apply," Click here>>