Learning from Every Patient

A Newsletter for Frontline Healthcare Team Members and Quality Improvement Professionals

Real cases. Practical improvements. Stronger voices at the bedside.

From HB Healthcare Safety® and Influence Ignited!

Edited by Jeanne M. Huddleston, MD, MS

Trivia Question: Respond to this Email for a Chance to Win

The Trivia Question Drawing for the $100 gift card continues. Read to the bottom, reply to this email with any answer, and your name is entered — correct or incorrect, it does not matter. I respond to every one.

Last newsletter's question: Who coined the term “second victim” — the clinician who is wounded by their own involvement in an unintended patient harm — and in what year?

The answer: Albert W. Wu, MD, MPH, of Johns Hopkins, writing in the BMJ in 2000 — a two-page editorial titled “Medical error: the second victim. The doctor who makes the mistake needs help too.” Twenty-six years on, the field is still arguing about whether the term should be retired. The condition it names has not been.

This issue's Trivia Question appears below. Read to the end!

Is it possible to be so committed that you fail?

BLUF: The most consequential failure of my career was not a failure of effort or capability. It was a failure to look in the mirror.

The Case

Our 100% multidisciplinary mortality review team identified that one patient died on our general medical floors approximately every three days as a consequence of unrecognized clinical deterioration.

The failure was not one of detection at the bedside. In most instances the deterioration was observed. The nurses caring for the patient recognized the change. But they did not perceive that could act on it. They documented "service notified" repeatedly. They voluntarily increased their workload by documenting frequent vital signs. They did not escalate the concern within their own chain of command. They had received negative pushback for activating the rapid response team in the past. The escalation pathway ran upward through a hierarchy constructed over decades, each layer of which had been added for a defensible reason. Information moved through it slowly, or it did not move at all.

An excellent hospital, staffed by excellent people, operating in a structurally broken system. We all knew it. Now with our mortality review data, we had the data and the stories to drive meaningful change.

Our Failure Mode and Effects Analysis FMEA) showed the dominant failure modes were not equipment, staffing, or protocol. They were cultural. We were not listening to one another.

The Encounter

We had leadership permission to move forward with identifying projects that would address the top five failure modes. They were all successful and we drove our raw mortality rate statistically lower and saved lives. One patient every 15 days instead of every 3 days. We were on a roll fixing the process and system failures. Now it was time to address the cultural issues to make the organization'a accomplishments permanent. We developed a system for automated escalation of expertise at the bedside. This would address the unspoken fear, hierarchy, confusion, distrust, ambuiguity, etc in healthcare organization's culture that lurks between a leader's intent of excellent outcomes and the fronline reality of caring for complex patients. We tested the new system involving machine learning and a strict rule that nursing workload must decrease. Not only did it work, but we found our "golden hour" on the randomly selelcted floors. Treatment >one hour sooner for septic patients. I presented these findings to the enterprise committee — the analysis, the failure modes, and a proposed design for dissemination across hospitals.

The chair listened. He then pushed his chair back from the table, folded his arms, and said: "Just tell the doctors to listen to the nurses. We don't need to do all this."

The nonverbal signal was unambiguous. I had twenty years of successful intrapreneurship in this organization. I knew how to read a room. But not that day, month, or even quarter. reading precisely that signal at the bedside. I had a major blind spot.

I responded — and I was aware of my tone as I spoke — "We've been doing that for more than 100 years. So while you do that, I am going to work on fixing the system to break through that culture." I held no influence over individual physicians' listening behavior. Nor did I have sufficient time remaining in my career to alter a communication culture that had persisted for more than a century.

Every statement I made was accurate.

Accuracy and effectiveness are not the same thing. I have had 15 years now to consider that distinction.

The Outcome

Our well architected system, with appropriate considerations for human design at the frontlines, was not spread. I never presented to that committee again. I was never tapped for a practice leadership position at that level again.

It is important to call out what I did, and did not do, in order to share this hard lesson with you. I was not under-invested. I was over-invested to the point that I lost my ability to see how my words and bearing were impacting those around me. I lost my personal mirror somewhere along the line. Normally, I can sense the signals to stop and return to discovery mode to figure out why my approach is off. Instead, with every barrier we faced, I pushed harder. That is the defining property of a blind spot, and it is why the correction has to come from someone else. My team was so loyal to my "cause" of saving lives that in our hierarchical culture, they did not call me out on my laser focus on the singular outcome as opposed to the process of improvement. My most honest critic, my husband, was deployed in Afghanistan. So I charged blindly forward in the name of saving more lives.

Analysis: Two Perspectives, One Structural Gap Between Them - The Messy Middle

BLUF: The two different perspectives are real.

As I visualize that meeting room, I can still see exactly where I was sitting, where the leader sat, the other people in the room, and the diagrams projected on the screen. The two perspecties of leadership intent and frontline reality were both fully visible, even palpable. However, the distance between their perspectives and needs were not going to spontaneously move closer to each other. Yet, without a shared understanding of the system as a whole and the impact it was having on both organizational outcomes and the patients - whose aggregate outcomes create the metrics, nothing was going to change.

The frontline perspective was one of constrained agency. The nurses had the knowledge and experience, but ran into the structural barriers that directly impacted the safety of their patients. Each unheeded escalation reduced the probability that they would attempt the next escalation, which is why cultures of this type are self-reinforcing rather than self-correcting.

The leadership perspective was one of resource stewardship under uncertainty. The chair was accountable for clinical practice across an enterprise with finite capital and a line of people demanding their piece of the pie. He had almost certainly observed a decade of culture-change initiatives that consumed budget and produced no lasting outcome. Testing the least costly hypothesis first is not a permanent "no"; it is fiduciary behavior, and from his position it was the responsible first decision in the flowchart of organizational prioritization.

Both perspectives are correct from their own vantage point, but the distance between them is real. This distance is what I have come to call "The Messy Middle".

My growing blind spot led to my personal primary failure mode. I chose sides. I chose the frontline perspective and solitary desire to remove their barriers at all costs. As a result of choosing, I lost the ability to be effective.

The work required in that room was translation — demonstrating the frontline bedside observations into terms the executive committee could act upon, and translating the executives' accountability and goals into terms the frontline could understnand and be motivated to follow the direction. That translation is the only thing that can move the two different perspectives closer together to create shared understanding and direction. Unfortunately, it does not arise spontaneously in most organizations.

I did not translate. I charged forward blindly.

Three Sessions, Three Phases — One Master Session Done - Next Two Happening This Week

BLUF: Someone has to wade into the Messy Middle and do the translating work if lasting and meaningful change is going to occur.

This translating work is the operating system that allows us to use the tools we have been taught during our QI professional development. Wading into the Messy Middle to do this translation work is a skill, not a personality trait. I am teaching all three phases of the translation work in The QI Operating System. Free, sixty minutes each, and the recording goes to everyone who registers.

PREPARE was held last Friday, August 14. COMMIT and ALIGN. How to operate and navigate inside a complex organization by effectively translating between the leadership's intent and frontline reality.

PRIORITIZE — Tuesday, August 18, 2:00 PM ET. LEARN and ANALYZE. How to get the data you actually need to choose what you work on first.
https://influence-ignited.kit.com/06c7242b6e

PREVENT — Wednesday, August 19, 2:00 PM ET. INNOVATE and DISSEMINATE. How to make an improvement survive the person who built it, after you have rotated off the unit.
https://influence-ignited.kit.com/4d1b3c8907

The three sessions stand on their own. They are also the front door to the full QI Operating System™ course, which begins August 21 — five weekly live sessions, live Q&A, and private 1:1 coaching. Details at https://hbhealthcaresafety.org/QI-OS/. SLS Collaborative/current PSO members participate at no cost; Alyson will sort that out — johnson@influenceignited.org.

Framework: Commitment as a Measurable Precondition for Success

BLUF: Personal commitment fails in two directions — under-commitment and over-commitment — and both can determine the outcome before the work begins.

Under-commitment presents predictably. Some months into a project the individual recognizes that the obligation cannot be met: the clinical load has changed, a family circumstance has intervened, or the original estimate was simply wrong. I said yes reflexively for twenty-five years, having been formed in a culture in which agreement to a leader's request was the expected response. That culture produced some of the finest clinicians I have practiced alongside, and I would not trade my training in it. But I assessed capacity only at the level of the organization and system — staffing, budget, timeline — and never at the level of the individual on my team, let alone myself.

Over-commitment is the less examined failure and, in my experience, the more damaging of the two. My lack of self-awareness and personal blindspots at the time not only impacted my career trajectory, but the outcome of a project that intended to save lives.

I now assess personal capacity across six domains before accepting any project: social, mental, physical, spiritual, energy, and time. I must rate each of them with blunt honestly, because I tend to overestimate my capacity in all six. Overestimation is not a private matter. The consequence distributes to the team members, their direct reports, and to the frontline care team members touched by leadership decisions.

I need to introject a squirrel (read sidebar) for two important distinctions I learned with this experience.

1) Commitment is not the same thing as buy-in. For twenty of my thirty years in this work, I treated a leader's assent, nodding heads in a meeting, as a commitment. But this Buy-in is passive agreement. Commitment is the allocation of resources, air cover, time, political capital, and a name for the sponsor who keeps this commitment.

2) The sequence of obtaining stakeholder commitments does NOT start with leadership. This is a practical implication for the essential information required to be successful. The first commitment to test is not the executive's. It is the frontline's. Approach a physician, nurse, respiratory therapist, etc., at two o'clock in the morning say, "Hey, I heard your floor was having issues with 'x'. I had this crazy idea to do 'y'. What do you think?" The response — engagement, indifference, or dismissal — is available within thirty seconds and is more predictive than any executive endorsement. Where the answer is consistently no, there is generally a different intervention the same people will support, and it is worth the time to find it.

Never forget that improvement in patient outcomes requires the people doing the work to change their behavior. Your great ideas and properly used QI tools are, unforntunately, insufficient.

The counterexample from my own record is the mortality review program. Rather than distributing findings that identified opportunities within colleagues' areas, I conducted a listening tour of more than eighty physician and nursing leaders, individually, thirty minutes each. I brought a de-identified case from the leader's own area and asked a single question: before this is disseminated, to whom would you have it sent? Then I stopped speaking.

I anticipated rejection. The response was near-uniform interest. It was the only mortality data in the institution that was not two years old.

By the time the proposal reached leadership, the decision had effectively already been made.

The commitment was identical in both instances. The allocation of it was not.

Reflection

BLUF: The failure mode we are trained to watch for is insufficient investment. In thirty years I have not once observed that to be the mechanism of failure.

Before your next project, name the one thing that reliably brings you to your knees and derails your professional work. For me it was a family member's illness when my husband was deployed in Afghanistan. I just wasn't effective professionally. You don't have to disclose what it is for you. It does need to be known.

And if you have your own experience with overcommitment — the meeting in which you were correct, but not effective, or the initiative you could not set down when the evidence indicated that you should — I would like to hear it.

I still see him push his chair back from the table. Fifteen years later.

Now, I see it when it begins to happen.

Now, I can provide feedback and coaching for others in the moment.

Now, I know when my ability to commit is compromised by factors outside of the project and organization.

Now, I can course correct in the moment.

Learning from Every Patient Newsletter Trivia Question

The first portion of the PREPARE component of the QI Operating System Course is the DISC communication style assessment— D, I, S, and C, and what each of us reaches for when we become dysregulated. The man behind that model had a second career you would not guess.

Trivia Question: The psychologist whose 1928 book Emotions of Normal People gave us the DISC model also created which comic-book superhero?

Just hit reply and type an answer. Correct or incorrect, you are entered into the $100 gift card drawing. Winner announced on the first day of the quarter.

About this Newsletter

Learning From Every Patient is a case-based patient safety and quality newsletter for frontline clinicians and healthcare quality improvement professionals who want to stop the unintentional harm caused by healthcare delivery. Each issue features rotating content, including real cases, expert commentary, a short “Loved One Lens” reflection, a brief look at “what worked” in successful improvement efforts, tips and tricks for quality improvement and patient safety projects, and quick scans of relevant new evidence. Published by HB Healthcare Safety, SBC, and powered by Influence Ignited!, LLC, the newsletter is edited by Jeanne M. Huddleston, MD, MS, and is designed to turn everyday stories and process defects into practical, actionable lessons you can use on your next shift.

Two Master Sessions Remain after today's— All Free, All 2:00 PM ET, Recordings Included.

Tue, Aug 18 — PRIORITIZE: https://influence-ignited.kit.com/06c7242b6e

Wed, Aug 19 — PREVENT: https://influence-ignited.kit.com/4d1b3c8907

QI Operating System Course— Register Now. Discounts for groups of 3 or more. Live training sessions, live Q&A sessions, small group work, private 1:1 coaching with Dr. Huddleston

Begins Friday, Aug 21 — https://hbhealthcaresafety.org/QI-OS

By learning from every patient we encounter, we will have the data and the stories needed to influence improvements.

Remember that behind every QI project is a patient, and healthcare team members, who need us to finish.

Editor: Jeanne M Huddleston, MD, MS

Founder, Influence Ignited, LLC

Co-Founder, HB Healthcare Safety, SBC

Professor of Medicine, Mayo Clinic College of Medicine

huddleston@hbhealthcaresafety.org OR huddleston@influenceignited.org