Tuesday, September 9, 2014

Tip 42: A Culture of Silos and Silence

Welcome Back.

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.”

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In The News...

A Patient Dies. A Hospital Heals

By Bill Santamour
H&HN Managing Editor

A fictional account of a tragedy and how a hospital changes for the better.

A patient dies after surgery despite the fact that checklists and other cutting-edge policies are in place to prevent such a tragedy. The clinical staff become defensive. Physicians close ranks to deflect blame. Nurses know that if somebody has to take the fall, it will, no doubt, be one of them. The hospital CEO understands that the fault lies not with individuals or policies, but with a staff too focused on their own task-filled workdays to see the bigger picture and too cynical to believe that things can ever fundamentally change. And the CEO herself is so overwhelmed by putting out everyday fires that she has no time to think about long-term solutions.

That’s the set-up of Heroes Need Not Apply, Brian D. Wong’s fictional account of Angels Hospital and the aftermath of a patient’s death, a death that could and should have been prevented. Wong, an M.D. and founder of The Bedside Trust, paints a familiar picture of today’s hospital staff, in which the sincere goal of putting the patient at the center of everything they do can get lost in the crush of workloads, silos, egos, long-standing hierarchies, skepticism and plain fear. His vivid cast of characters includes a brilliant but intransigent surgeon, a young doctor with conflicting loyalties, an outspoken nurse, a new CEO and the person she brings in to help change the culture.

OK, I can see you rolling your eyes at the term “change the culture.” But by getting inside each individual’s mind and allowing us to listen in on their thoughts and conversations, Wong avoids consultant jargon and preachiness. He presents a true-to-life scenario of personality conflicts common to all hospital staff and the endemic skepticism that often straitjackets any leader’s efforts to foster meaningful change. And he shows how a hospital CEO can overcome those obstacles to, as the book’s subtitle puts it, “build a patient-accountable culture without putting more on your plate.”

The crux of that culture change is eliminating the chain-of-command structure and moving to one in which listening and respect across job titles and individuals can lead to true team care. As someone at Angels Hospital says, “No one person, no matter how smart, was nearly as smart as a roomful of people.”

In his introduction, AHA President and CEO Rich Umbdenstock writes that Wong’s story “brings a human element to the equation and underscores the importance of making patients and their families full partners in the care process."

Heroes Need Not Apply is an excellent resource for you and your physicians, nurses, C-suite and board members. Might even make a good stocking stuffer. For more information, click here.

The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.

H&HN Daily, December 10, 2013

Heroes Need Not Apply... now on eBook

Kindle  iBookstore   Nook
Dr. Brian WongImproved care coordination is essential to gaining the efficiencies required in this healthcare reform era. To move metrics in patient safety, experience, and quality, we must become effective at delivering coordinated team based care.

In his new book, Heroes Need Not Apply, Brian Wong MD, uncovers the reasons why many of us experience spotty improvements in patient safety, episodic service excellence, and insufficient engagement and accountability. To make sustainable improvements, we need to know how to migrate from a system that can best be described as uncoordinated (i.e. poor hand-offs, suboptimal staff interaction, medical hierarchies, etc.) to one that delivers consistent coordination of team based care.

The purpose of Heroes Need Not Apply is to give healthcare organizations a template for creating a strong foundation for effective coordinated care.  This “how-to” book gives every executive, physician, nurse, and clinical team member the tools to make specific changes at the local level, and uses relatable characters to showcase effective patient-centered skills to improve efficiency, decrease costs, and improve the patient experience. If your hospital is looking to accelerate improvements in care coordination and improve team care,Heroes Need Not Apply is a timely resource designed to equip your organization with the practical skills required for improved care coordination.

The book has already caught the attention of many top physicians, nurses, and executives as an innovative resource to lead our industry into a new era of value based healthcare that is both cost effective and accountable to patients. 
Dr. Wong's Heroes Need Not Apply is receiving praise by noted physician leaders and industry experts throughout the country...
“Heroes Need Not Apply examines the root causes of healthcare’s most pressing safety and quality challenges. It offers practical strategies to improve communication among staff, dismantle silos, and build high-performing teams.”
— Richard J. Umbdenstock, President and CEO of the American Hospital Association

“I believe this book will help save lives, improve quality, and recommit healthcare providers and patients to new levels of trust.”
— Sue Collier, MSN, RN, FABC - Performance Improvement Specialist, Patient-Family Engagement, NC Quality Center/NC Hospital Association

“Dr. Wong’s book “Heroes Need Not Apply” breaks new ground as a field manual for what WE can all do on the front lines to be leaders as opposed to “reactors’ of healthcare transformation.”
— Stephen K. Klasko, M.D., M.B.A., President and CEO, Thomas Jefferson University Hospitals
"...[Dr. Wong] speaks the truth of what we must become as leaders in health care."
— Jeff Selberg, EVP and Chief Operating Officer, Institute for Healthcare Improvement.

“Amazing! Timely, accurate, stunning, motivating, frightening. More than reading, I consumed the book. What a wonderful story of cold truth.”
— Jack Cochran, MD, Executive Director, The Permanente Federation, LLC

“On the journey to team-based and patient-centric care the evolving healthcare system is indeed a place to which Heroes Need Not Apply."
 Joseph S. Bujak, MD, FACP

“Dr. Wong draws the reader into the world of the hospital and an understanding of the cultural barriers that contribute so much to preventable medical error.”
— Gordon R. Clark, President and CEO of iProtean
On Sale Now!
Kindle  iBookstore   Nook
To order your copy today and/or get quantity discounts for your organization visit:

A portion of the profits from the sale of Heroes Need Not Apply goes to support the Josie King Foundation.
Dr. Brian Wong
To learn more about Heroes Need Not Apply, and/or schedule an author’s interview for your organization please Click here>>
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