Let’s All Feel Superior: Individual Failures Require Leadership, Systems, and Culture to Bind

I read this op-ed piece from David Brooks in the New York Times with great interest. While talking about the Penn State scandal, Brooks identifies several fascinating psychological constructs that we use as individuals to avoid taking the "right action":

• Normalcy Bias - "shut down and pretend everything is normal" 
• Motivated Blindness - "don't see what is not in their interest to see" 
• Bystander Effect - "the more people are around to witness the crime, the less likely they are to intervene" 
• Self Deception - "we attend to the facts we like, and suppress the ones we don't" 
• Blind Spots - "when it comes time to make a decision, our thoughts are dominated by thoughts about how we want to behave; thoughts of how we should behave disappear" 

His key point is that we're in denial of "the underside of our own nature", which I would have to believe is likely true. However, as Brooks also points out "in centuries past people built moral systems that acknowledged this weakness .. they helped people make moral judgments and hold people responsible amidst our frailties." I would argue that this is the real weakness. Human nature has not changed, but society has evolved into such a complex organism such that the systems to keep "human nature in check" are not functional.

But this is ultimately what is means to be a leader - whether spiritual, political, or organizational - and to create an organizational culture: help to guide human nature - despite its many failings, blind spots, self deception, and biases - to achieve a purpose and pursue actions that no individual would undertake on his/ her own.

Many of us see these individual failings consistently in our healthcare organizations, which have largely been build around the notion that failure of behavior is an individual failing. Sometimes these individual failings are just as egregious as the examples used by Brooks when staff, managers, and executives "stand by" and allow for actions to be taken that lead to patient harm in the guise of "its just the way things work around here".

However, as many industry leaders have been pointing out - particularly the stalwarts for patient safety - individual behavior may contribute to a failing, but it is not the cause. The system (i.e., culture or society) that allows that behavior to be manifest is the cause. If we want better behavior, decisions, actions or ultimately the outcomes which result from these behaviors, then we have to work with greater diligence to build the leadership, systems, and culture that will allow individual failings to be overcome or at least held in check. The likelihood of harm is just as great, and not at all excused because the victims are sometimes unknown, or because it happens within a building and not on the street.

Performance Improvement Tip of the Day: A "SMART" PI Project Checklist

In this "list-obsessed" world of ours, its hardly a surprise that one would create a "Checklist for Checklists". In healthcare, the call has gone out from Drs. Peter Pronovost and Atul Gawande to introduce Checklists as "patient safety tools". They are particularly useful when dealing with complex systems, and for reminding personnel of "basic operations" that can't be forgotten. When used properly, Checklists can ensure that necessary aspects of care are delivered, and free up highly trained personnel to think about when to deviate from a Checklist, and focus on higher level decision-making.

As we make our performance improvement teams more results-oriented, the Checklist becomes a useful tool to help keep the projects themselves on track. This helps to remind our project leaders about the steps they need to take in order to ensure that project goals will be met.

The "SMART" PI Project Checklist below - in keeping with our "SMART" theme - helps to provide a relatively simple, easily implementable framework for delivering improvement. In this context, "SMART" reminds us of the following:

• When designing Goals, Feedback, and Profiles, keep them "SMART" in order to ensure efficiency and minimize the likelihood of resistance or conflict. See prior blogs on each of these topics for more details.
• The "SMART" PI Project ensures that we:
• "Specify" ownership of the project.
• "Monitor" results in an ongoing fashion, and ensure that others in the organization help us with the monitoring.
• "Analyze" the current system in order to properly develop Goals, identify Barriers, and identify the Critical Processes that need to be undertaken in order to deliver results.
• "Redesign" the system intelligently building in decision support to ensure reliable outcomes, and enhancing safety mechanisms to catch problems real-time.
• "Train" ourselves, our staff, and our leaders to deliver better results using proven "behavioral management" techniques of Feedback and Profiling.

While this list can be individualized for the needs of particular institutions, the elements included are generally those that I find essential in delivering results. As you work through the list, you are introducing greater reliability into the system and establishing an increasingly mature culture of improvement.

Performance Improvement Tip of the Day: Embed the Desired Practice into the Clinical Workflow

This document illustrates a very simple improvement principle - in order to ensure that the desired practice is undertaken, embed it within the clinical workflow.

In this example, ordering of DVT prophylaxis was embedded into the tool that clinicians used to admit all patients - the General Admission Order Set. Multiple prior iterations of a separate "DVT order sheet" were tried but failed, because it was "yet another document that clinicians had to remember to grab".



Once the desired practice was built into this order set, the resultant ordering of DVT prophylaxis improved considerably. The issue in this case was not that the clinicians were unaware of the need for DVT prophylaxis nor that they were resistant to the same, but simply that the appropriate reminder (AKA checklist) was not presented to them at the time when they were most likely to write this order. A simple reminder, including the most common orders for DVT prophylaxis, provided at the most clinically opportune time gave the clinicians the precise "decision support" they needed to ensure safe practice.

The DVT Prophylaxis section is highlighted here:


We also included "decision support" on the reverse-side of the paper-based orders so that staff had an immediate reference handy to support their decision-making:

Use of Checklists Could Help Improve Transplant Safety

Interesting article in the Boston Globe today about changes being made to the Lahey Clinic Transplant Program after a number of adverse events were noted in patients.

http://www.boston.com/news/science/articles/2011/10/21/lahey_clinic_revamps_transplant_program_after_kidney_failures/?page=1

Obviously hard to know from the outside all of the details of the issues and the actions taken, however, some of the writeup excerpted above alludes to changes that could be addressed by a "checklist" process, such as the simplistic sketch below:

Drs. Peter Pronovost and Atul Gawande have researched and written eloquently about the use of checklists to improve safety in healthcare. Those of us on the administrative and clinical front lines need to heed their recommendations for implementing this relatively simple tool that has the potential to prevent adverse events, improve outcomes, and improve reliability of care.