A Key to Patient Safety — Don’t Just Listen, Solicit Input

New blog post in BMJ

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suzanne_gordonWant to be a better physician or nurse leader? Enhance patient safety? Effectively lead teams? One of the current consultant prescriptions is the recommendation that leaders spend more time listening than talking. Whether in the larger management literature or in the articles and books that specifically target healthcare, listening is portrayed as a key to leadership.

I am all for listening. Of course people have to listen to each other rather than silence, ignore, dismiss, or denigrate one another. When it comes to the implementation of genuine teamwork and patient safety within the hierarchical environment of health care, I don’t think listening is enough. As Amy Edmondson has written in her book Teaming, “Research shows that hierarchy, by its very nature, dramatically reduces speaking up by those lower in the pecking order. We are hard-wired, then socialized, to be acutely sensitive to power, and to work to avoid being seen as deficient in any way by those in power.”  READ MORE

Don’t Just Sit There Listening –Solicit Input

image-asking-questionsindexSoliciting Not Just Listening

Want to be a better physician or nurse leader? Enhance patient safety? Effectively lead teams? One of the current consultant prescriptions is the recommendation that leaders spend more time listening than talking. Whether in the larger management literature or in the articles and books that specifically target health care, listening is portrayed as a key to leadership. Employees want their voices to be heard,” one management guru opined in a Forbes article entitled “6 ways Effective Listening Can Make You a Better Leader,” and to “know that they (their leaders) have their interests at heart because they really listen.”

To emphasize this point psychiatrist Mark Goulston titled his bestselling book Just Listen: Discover the Secret to Getting Through to Absolutely Anyone. Listening 1.1 has, in fact, advanced to listening 2.1 wherein one is exhorted not to “just listen” – i.e. passively and unresponsively — but to engage in “active listening.”

I am all for listening. Of course people have to listen to each other rather than silence, ignore, dismiss, or denigrate one another. When it comes to the implementation of genuine teamwork and patient safety within the hierarchical environment of health care, I don’t think listening is enough. As Amy Edmondson has written in her book Teaming, “Research shows that hierarchy, by its very nature, dramatically reduces speaking up by those lower in the pecking order. We are hard-wired, then socialized, to be acutely sensitive to power, and to work to avoid being seen as deficient in any way by those in power.”

Whether it’s nurses dealing with doctors, junior doctors dealing with senior ones, or patients dealing with the “team” that is supposed to be centered around their needs, subtle or overt manifestations of power hierarchy all too often defeat admonitions that people should speak up.   To remedy this requires more than active listening, it requires actively soliciting input from those on the team, particularly those lower on the totem poll – which includes not only staff but patients.

Frontline staff are often reluctant to speak up, tell higher ups when something is wrong, warn them about a potential catastrophe or even just an everyday glitch. They are equally hesitant to cross-monitor members of the team and help maintain situational awareness by providing new – and not always welcome –information. As for offering their ideas for innovation and quality improvements, they may feel no one is interested or will listen. To counter these entrenched beliefs and perceptions – which are often based on past experience – requires a leadership commitment to aggressively solicit input rather than waiting for staff – whether professional or non-professional – to tell leaders something they need to know.

Soliciting input – and then actively welcoming it – can do a lot to help people see that it is safe to admit error, provide a needed warning or heads up, convey new information and update their colleagues and co-workers about the latest developments or changes in a situation.  Asking people –and this must include patients –what they think, what they’re worried about, if they agree with, or understand a plan of care and then respectfully responding to the need for clarification or further information gives people permission to speak up. This is critical when working with professionals or other healthcare workers and even more so when dealing with anxious, frightened, and vulnerable patients. In an environment in which people may be reluctant to speak up because they have not traditionally felt that it was psychologically safe to do so, soliciting input as a kind of “standing order” builds the foundation upon which effective listening is built.

Consider for example, how aviation moved from a being a very risky to a highly reliable industry. One of the many things captains and pilots, and other team leaders are taught to do in recurrent team trainings is actively solicit input from their crews. In one Northwest training video, a captain enters the cockpit and tells his crew , that although he is the senior officer, he wants them to let him know if they see him making a mistake. When captains do their briefings with first officers and cabin crew, they always ask those lower in rank if they have any concerns. If such concerns are expressed, then they apply so called active listening skills in responding to them. They also alert their teams to any personal or physical problems that might impact their performance and ask one another—even those lower in rank — to cross monitor them as they do their job.

In health care, which has staunchly resisted systematic teaming training, anecdotal evidence and research data document that leaders who do this are the exception not the rule. Which is why the skill of soliciting has to be both preached and practiced.

Consider a few examples.

A physician wants to discharge a patient to his home with a complex regimen of IV medication that the patient’s wife will have to administer at home. The patient’s nurse, and social worker, not the physician, have a great deal of information about the wife’s ability to deal with her husband’s medication regimen. The physician does not, however, solicit input from either nurse or social worker about the wisdom of his plan. Instead he simply orders nurse and social worker to prepare for the discharge. As a result, the patient’s wife becomes extremely upset, which generates a day long conflict in which the physician becomes increasingly frustrated as the nurses and social worker hint at, rather than clearly discuss, the problem and remedy – a delay of one or two days in the discharge.

Imagine what would have happened if the physician had gone to the social worker, and the nurse – as well as the patient’s wife – and solicited their input by asking if they thought his plan was reasonable? The result would have been the same – a delayed discharge – but the destructive conflict would have been avoided and all would have felt they were members of an effective team.

Or consider the dilemma relayed to me by several attending physicians on a neo-natal ICU at a major teaching hospital.   The NICU attendings said they constantly tell their residents to call them with any problems they have on the weekend or at night. Because many residents are afraid they’ll get a bad mark if they express confusion or ask for help, they don’t get a lot of calls even though many residents have lots of questions. What’s the solution? Soliciting input.   As my colleague neo-natalogist John Chou recommends, attendings can pick up the phone, call the unit, page the resident and then say, “hey, I know we have this very sick patient. We haven’t talked in a while, and I just wanted to know if you had any questions or concerns I can help with?”

When soliciting input is accompanied by a genuine offer of help – rather than appears in the guise of quizzing or passing judgment – Chou says, he always learns about critical details that can impact the course of a tiny pateint’s life.

Finally, I can say as a patient, that when a physician asks me what I think about the treatment he or she is about to recommend (something I have occasionally experienced), wonders if I will have any problems with it, or follows up with a call asking me how things are going, my trust in that caregiver and willingness to follow the recommended treatment increases exponentially.

It’s pretty simple, when you ask you might hear something that is actually worth listening to.

Hey Manners Matter: Say Hello My Name Is Not Just to the Patient

Why Introductions Matter Is a New Post I did at the BMJ

suzanne_gordonThe other day, I was invited to give a seminar on interprofessional teamwork to a group of residents and attendees at a prestigious university medical center in Europe. The first thing people did when they trooped into the room was introduce themselves to me. Since there were about 25 people in the room, no one really expected me to remember their names. But each and every one of them went through the drill.

These introductions did more than convey instrumental information about who we all were and what roles we had. At the most fundamental level, what people are doing when they acknowledge a stranger walking down a street or shake the hand of a person whom they have just met is create a psychologically—not to mention physically—safe environment. Read More

 

BMJ Post Sitting at the Table or Not

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suzanne_gordon

The oval, mahogany table dominates the center of the large conference room. A number of chairs circle the table and dot the perimeter of the room. Every week, a group of high level hospital administrators, physician leaders, and leaders of other professional and occupational disciplines—physical therapy, social work, clinical directors of nursing, housekeeping, etc—gather in this room to discuss hospital function. They call themselves a “team” and the gathering a “team meeting.”

Nothing indicates that places at the table are reserved for particular participants. But today, as happens every week, when physicians and hospital administrators enter the room, they immediately occupy the chairs at the table. As nursing and other professional and occupational “leaders” enter the room, they sit around the perimeter, even if seats at the table are empty. The discussion is largely conducted by, and includes mostly, people sitting at the table. Occasionally, someone chips in from the outfield, as it were, but not too often and certainly not with much vigor.

I have been invited to this hospital to consult about teamwork, patient safety, and “professionalism” particularly among the nursing staff. The hospital has sent people to do TeamSTEPPS, a healthcare team training developed by the Department of Defense and the Agency for Healthcare Research and Quality. It has hired consultants to teach people the principles of high reliability organizations (HROs). It is concerned about the fact that non-physician personnel do not speak out about patient safety and, as the Chief Nursing Officer puts it, do not behave in a “professional manner” when at work. Maybe, she muses, nurses would speak up more if they all wore a standard uniform instead of scrubs adorned with flowers or smiley faces. Come and observe us function, and tell us what you think, is my mandate from the executive team.

So when I observe how “team” meetings are conducted at the highest levels, I am expected to ask some questions. Which I certainly do.

After the meeting is over, I ask nursing clinical directors and “leaders” in social work and other disciplines, why they do not take a seat at the table when one is empty. They all say they same thing.

“Those seats are reserved for physicians and hospital administrators.”

“How do you know this,” I ask, “were you specifically informed of this rule?”

“You don’t have to be told,” they reply, “We just know.”

” Why do non-medical personnel speak so infrequently?” I then query.

“Well,” someone stammers, “it’s not clear anyone really wants to hear from us.” They also add that when non-physician staff finally do say something, they do it tentatively, rather than presenting their concerns in a compelling and confident manner. Or they stick to commenting on issues pertaining to their particular profession or discipline, even when they have things to say about broader issues. They say they tell me that they know it’s critical to have new perspectives on patient care issues, but they just don’t feel safe to address them.

In their excellent paper on the choreography of power during morning rounds, Elise Paradis, Myles Leslie, and Michael Grooper point to the same persistent problem in a year-long ethnographic study of morning rounds. They report that, “Operational conditions on the units, despite interprofessional commitment and engagement, appeared to thwart ICU teams from achieving these goals. Specifically, time constraints, struggles over space, and conflicts between morning interprofessional rounds. Educational and care-plan-development functions all prevented teams from achieving collaboration and patient involvement. Moreover, physicians’ de facto control of rounds often meant that they resembled medical rounds (their historical predecessors), and sidelined other providers’ contributions.”

Institutional leaders may exhort staff to speak up to protect patients, present their ideas for quality improvement, and help build a high reliability organizations. They may even provide some training in the skills needed to enact teamwork and high reliability. These, however, may be undermined by behaviors that reinforce traditional patterns of reverence and deference and locate “expertise” and vest authority in those who have the most years of higher education and initials after their last names.

One of the most critical tenets of high reliability is deference to expertise. In their book Managing the Unexpected, Weick and Sutcliffe define expertise in terms of front line experience, with decisions and authority, as they put it, migrating to people “with the most expertise, regardless of rank.” When rank defines authority and expertise, it undermines the kind of psychological safety, Schein and Bennis and then Edmondson describe as critical to institutional learning and safety.

As we saw in the “team” meeting described above, you don’t have to tell people to “shut up” in so many words. Particularly when you are dealing with “lower status” groups, all you have to do is send signals that they and their input is unwelcome. If a nurse or social work leader is informally prohibited from sitting next to an MD or executive at a conference table during a meeting about quality and safety, is it surprising that nurses on the wards won’t tell a physician he has forgotten to clean his hands or that she is about to deliver the wrong dose of a medication?

We have largely left the era when surgeons throw scalpels in the OR and physicians expect nurses to give them their chairs when they enter a room. What we have not engaged in, however, is the kind of profound behavioral culture change that helps people check their concern for status at the door so that they can learn and listen from people who are not at the same level in the hierarchy as they are. This requires not only an actual seat at the table, but inviting input of not the usual suspects, noticing silence, and helping people to contribute. So keep your eyes open. When you see a circle of exclusion, expand it and invite people to enter. Don’t wait for people to speak up, ask them about their concerns. And most importantly, when someone of lower rank sits on the periphery when a chair is open at the table, ask them to fill it.

Suzanne Gordon is a healthcare journalist and co-editor of  The Culture and Politics of Healthcare Work Series at Cornell University Press. Her latest book is Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, which she co-edited and she is co-author of Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety. Most importantly she is a patient.

New Blog Post about VA at BMJ

This was just posted on the BMJ blog.  

Hope people will read and pass it on.

suzanne_gordonBy the end of this year, the US will have a new president as well some new members of Congress. The results of the 2016 election will not only effect the further implementation of the Affordable Care Act (Obamacare), but the future of the country’s largest healthcare system—the Veteran’s Health Administration. That’s because most of the Conservative Republicans running for President—as well as many of those running for or already serving in Congress—are not only determined to repeal Obamacare. They are also committed to dismantling the largest and only publicly funded, fully integrated healthcare system in the US—the Veterans Health Administration (VHA). Even many Democrats are not fully supportive of the VHA. While Hilary Clinton says she does not support privatization of the VHA, only Bernie Sanders (D. VT) has demonstrated a deep understanding of what the VHA does and how it actually works.

The Veterans Health Administration grew out of Abraham Lincoln’s Civil War pledge “To care for him who shall have borne the battle and for his widow, and his orphan.” Since World War Two, the VHA has become the largest and only fully integrated, publicly funded healthcare system in the United States. Its 1700 sites of care include more than 150 medical centers, 1000 community based outpatient clinics (CBOCs), and other mental health, nursing home facilities, and in and outpatient facilities.

The VHA has over 260,000 employees, over a third of whom are veterans. Its tripartite mission includes the delivery of clinical care, research, and teaching. Since 1946, the VHA has affiliated with major academic teaching hospitals and now trains over 70% of American physicians as well as students and trainees in 40 other healthcare professions. It’s vast research arm has produced innovations that have improved the health of veterans suffering from illnesses like Post Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI), as well as spinal cord injury. VHA research has also produced innovations that help all patients. To name only a few, the VHA developed the first implantable cardiac pacemaker, performed the first successful liver transplant, helped to test the Shingles vaccine and develop the nicotine patch.

Republicans have consistently refused to adequately fund the VHA and have resisted expanding its services to all veterans. The VHA only serves veterans who have some form of honorable discharge and who have service related disabilities and/or low incomes. The result is that the system takes care of the oldest, sickest, and poorest veterans. The average VHA patient is 62 years old, has multiple physical co-morbidities and a higher percentage of mental health problems than the average patient in the private sector. In spite of this significant challenge, an Independent Assessment of the VHA’s record on care delivery, mandated by the 2014 Choice Act, documents that the VHA outperforms the private sector on many measures, is equivalent on some, and marginally worse on only a few. Despite variability in the VHA system, the Independent Assessment repeatedly reports that the private sector healthcare system provides care with even more variability than the VHA. The Association of VA Psychologist Leaders recently posted yet another review of the scientific studies on VHA care which document similar outcomes.

Ignoring the VHA’s record of care delivery, congressional conservatives are exploiting the wait time problems and delays uncovered in 2014 in Phoenix and some other VHA facilities to argue that the entire VHA system is broken and that the VHA should no longer pay for and provide healthcare services. They want to eliminate the VHA and transfer veterans to the private sector healthcare system, with the government serving as payer, rather than also the provider of care.

Needless to say, this would be a huge boon to private sector hospitals, which is why many support this plan. It is also favored by large pharmaceutical and medical equipment companies. Big Pharma has long chafed at the fact that the VHA—unlike say Medicare or other US health plans—negotiates lower pharmaceutical prices through its drug formularies. Since VHA physicians and other staff are on salary, they have little financial incentive to either over or undertreat their patients and thus use medical equipment and treatments much more judiciously than their counterparts in the private sector. They have also developed more integrated mental health, primary care, geriatric and palliative care services than other US health plans.

Finally, the VHA has long been anathema to conservatives. As Alicia Mundy has recently reported in an article in The Washington Monthly, the Koch brothers have funded a group called the Concerned Veterans of America—a veterans’ service organization that has no veteran members and provides no veteran services.

The CVA has been lobbying for partial and ultimately full privatization of the VHA. The mainstream media have been filled with stories about VHA dysfunction. Media outlets have promoted this narrative and ignored continuing evidence that the VHA—in spite of wait time delays and top heavy management—continues to deliver high quality care to veterans.

As a result Congress is now considering two bills that could pave the way for the privatization of the VHA. At the same time, a congressionally mandated Commission on Care tasked with strategizing about the future of the VHA, is also dominated by discussions of VHA privatization.

Seven of the commission’s members have written a proposal entitled “The Strawman Document” recommending the total elimination of the VHA. The Strawman document has produced an outcry from veterans’ service organizations (VSOs). Eight of the nation’s largest veterans services organizations—including the American Legion, Disabled American Veterans, and Paralyzed Veterans of America, have written a formal letter to the commission to express their concern about the report. These groups support proposals, like that put forth by VA Undersecretary of Health David Shulkin, that would strengthen the VHA, give veterans the choice to see outside providers if necessary, but maintain the VHA as provider and coordinator of healthcare services.

The fate of VHA will affect more than America’s 24 million veterans and their families. With its research, teaching, and innovative models of team-based integrated care, the VHA serves as a model for quality healthcare delivery that should be emulated rather than dismantled.

Suzanne Gordon is a healthcare journalist and co-editor of The Culture and Politics of Healthcare Work Series at Cornell University Press. Her latest book is Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, which she co-edited and she is co-author of Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety. Most importantly she is a patient.

Competing interests: SG is currently writing a book about the VHA.