The following Coach Leader is part of our ongoing series based on the characters created in my book, Heroes Need Not Apply, “How to build a Patient-Accountable Culture without putting more on your plate.” The book shows how focusing on what matters most to patients, having the right mind-set and a common direction can bring people together to ignite an entire organization.
My characters, CEO Jane Carolli and VPMA Dr. Jack Martin continue to craft a strategy to improve their culture by developing a cultural assessment tool to help drive change.
As they build the tool, certain constants continue to surface, with importance of collaborative communication leading the list…
When Jane met Jack in the cafeteria for lunch, Jack was so engrossed in reading an note from a friend, she had to literally give him a nudge on the shoulder to get his attention.
“Earth to Jack, are you in there?”
“Sorry Jane, I just can’t get over this message I got from a physician colleague… it hits so close to home in so many ways.”
“What do you mean?”
“Well,” said Jack, “He almost lost his 91 year old mother to preventable errors a physician made, and more importantly, a number of staff members enabled his mistake to almost go critical by not holding him accountable.”
Jane grimaced, “I know what you’ve been going through with your mom Jack - there’s nothing easy about switching roles with a parent when they can no longer take care of themselves.”
“You’re right Jane, my mom immediately came into mind, but I feel very good about where she is… and honestly, I just can’t believe things like this are still happening… I mean, I know our industry is plagued by siloed cultures, but this is just ridiculous.”
“Clue me in Jack.”
“Well, this doc’s mother-in-law who lives in an Alzheimer unit almost died from an iatrogenic C. Difficile infection. Her doc lazily diagnosed her with possible bronchitis or pneumonia based on a history of cough, weakness and increasing cognitive impairment.”
Jane broke in, “What about his examination? Didn’t he take a sputum culture/gram stain or take an X-ray?”
“He didn’t even examine her. He phoned in a prescription of Augmentin and then waited a week to see her cough improve, only to have her develop abdominal pain, a fever and loose stools.”
“Surely then, he performed a comprehensive exam.”
“Nope,” said Jack, “ He just guessed again, and called in another antibiotic.”
“Okay Jack, I get it. We’ve got a burnt out doc here. Unfortunately it’s just getting worse - luckily we’re doing more every day to prevent this here at Angels.”
“It’s much more than a burnt out doc Jane… it’s how everyone else contributed to the situation… by not contributing at all. For instance, the family was told that the staff were well aware that their mother wasn’t given appropriate care and was prescribed antibiotics without complete or even minimal evaluations. They even suggested that my friend find a new doctor.”
Jane asked, “Surely someone reported the guy?”
“That’s the deal, nobody said anything - nobody held the guy accountable.
“Nobody wants to be accountable for anything,” said Jane in disgust.
“Right Jane, as my friend put it: “Active errors by a single individual at the frontline are seldom sufficient to cause an adverse outcome. It is when they are supported by a wealth of enabling passive systemic errors throughout the organization that the active errors result in potential harm.”
He continued, “This story reminds me of some research findings from a critical care nurse and physician survey. The study found that 84 percent of physicians witnessed co-workers taking dangerous short cuts and 88 percent of physicians witnessed co-workers making poor clinical judgments. Yet, 88 percent of nurses and a remarkable 99 percent of physicians were unwilling to confront a co- worker providing sub-standard care.”
Jane sighed, “And we wonder why we’re surrounded by cultures of silos and silence. We know that medical errors are going to happen, but without any cultural accountability in place, nothing’s going to change.”
“Well that’s why we’re doing what we’re doing Jane. We have to build a culture that starts with being more accountable to patients, and the only way to do that, is to continually assess what skills and behaviors need changing…and I can’t help thinking we need to continue to make this a priority.”
“Then we better get back to it Jack.”
Is your culture aligned to what matters most to patients?...