Dr. Cohn Facilitating Physician-Hospital-Board Retreat

• Communication
• Representation
• Incentives to improve
• Transparency
• Trust
• Engagement
• Reimbursement
• Speed

I know that this hospital will thrive for two reasons that I have discussed in previous posts: 

1) They are becoming comfortable with paradox: they have moved beyond finger-pointing and blame-storming toward embracing a common vision that requires both-and rather than either-or approaches; 

2) They have a collaborative culture: although physicians are not known for team behavior, they can accomplish great things together when they feel that they are making their time count. 

What do you think? 

• What variations of CRITTERS have you tried where you work?
• Are you reaching a balance between problem-solving and becoming more comfortable with paradoxes that you cannot solve
• Are you building a culture of collaboration from the ground up?

 As always, I welcome your input to improve healthcare collaboration. 

Kenneth H. Cohn 

© 2010, all rights reserved 

Disclosure: 

I received compensation for facilitating the hospital-physician-board retreat to accelerate physician-hospital integration. I have a warm, proud connection to the hospital mentioned herein.

Greetings from Prague, where the choral group in which my wife sings made its international debut.  Our activities included a tour of the Hradcany Royal Palace, which was a painless way of relearning European history.

I use the word “relearning” because I can remember the page from freshman year high school describing the defenestration of Prague May 23, 1618, in which over 100 Protestant nobles led by Count Thurn stormed the palace to protest the succession to the throne of the Habsburg Archduke Ferdinand, whom they regarded as intolerant.

Windows through which two Catholic governors were thrown

Depth to which Catholic governors fell

The Protestants confronted the two Catholic governors whom Ferdinand appointed and, failing to obtain satisfaction, threw them and their secretary out of the palace’s eastern window to the ground over 50 feet below, starting the Thirty Year’s War.  The three survived because they landed in a dung heap.

Next time that I feel overwhelmed, I will encourage myself to remember that being knee-deep in dung proved life-saving for two adults in 1618.  That battles can last thirty years reminds me of the long memories involved in physician-physician and physician-administrator disputes on which I am consulted.

 History can teach us perspective when we are open to learning.

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have not received any compensation for writing this content.  I have no material connection to the brands, topics and/or products that are mentioned herein.

Despite the stresses of moving, I am excited to buy a home that a builder built for himself.  As several people in construction have told me, builders use their knowledge, experience, and leverage with their subcontractors to make sure that they are living in a home that meets and exceeds specifications.

Steel girders supporting upper floors

My grandfather, who sold commercial real estate, told me to begin a tour of a house for sale at the basement, where one can see, feel, and even smell the quality of workmanship and attention to detail.  Witness the I-beams used in construction of skyscrapers that support the top two floors of my new home.

Two healthcare analogies come to mind:

1) During my residency, an attending surgeon stayed in the Operating Room until the skin incision was closed; he told me, “If patients see perfectly approximated skin edges, they assume that their surgeon paid attention to detail on the inside. First impressions count.”

2) When I help hospitals set up Physician Advisory Panels, I encourage them to pick physician co-chairs who, based on inside knowledge, are the physicians that physicians turn to for advice and care; these physician champions create a safe environment for learning and growth that builds transparency and medical staff trust from the ground up in the same way that a home builder starts construction with a solid foundation

Imagine the potential, as we design a system to deliver more collaborative cost-effective healthcare, of being builders designing a home that we are going to live in.  For those of us at or nearing our mid-century mark, the timing could not be more favorable.

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

In a previous post, I mentioned that the January 1, 2012 deadline for Accountable Care Organization (ACO) Medicare applications is rapidly approaching.

In a recent Advisory E-Alert, entitled the Hospital-Government Complex, Mark Weiss, warned physicians:

The fact is, the ACO is simply a model for hospital control of physician practices, cloaked in the respectability of quality of care. Tied to the focus given to the notion of paying for quality of care as opposed to simply the volume of care, pundits suggested that organizations linking hospitals, physicians and other providers can be used to contract together, take risk based in part on achieving quality (however quality is defined), and distribute the income.

The reality is that there is only one acronym at play here: PCN — Power, Control and Naiveté. Issues of power and control underscore all levels of healthcare. As to the “N” for naiveté, it’s yours that they are counting on.

 An ACO is about power and control over physician services rendered and, importantly, power and control over physicians’ incomes. ACOs are the intended funnel of payor funds – they serve as a mechanism to distribute those funds and, as such, invoke the Golden Rule: He who has the gold makes the rules.

 As a physician, if you think that it’s difficult to negotiate with third party payors or to obtain stipend support from the hospital to shore up declining reimbursement, think what it will be like when there is one real payor in town, the hospital-controlled ACO.

In Surgeon Frustration, I mentioned that we are no longer viewed as captains because we lack process skills in communication, win-win negotiation, and conflict resolution that are necessary for leadership.  However, the lessons that guide me through these uncertain times come from my inadvertent fellowship in oncology, when I received chemotherapy for lymphoma and learned the mope-cope-hope strategy for dealing with helplessness. 

I paradoxically derived strength from admitting that I did not have control and focused on what I could influence, especially my attitude toward helplessness.  I quoted Paul Tsongas’ book Heading Home about his battle with lymphoma:

Now the matter of belief is central to me and gives me a truer sense of direction.  These changes are a precious gift.  My illness gave them to me. I treasure them.

President Reagan told advisors who brought him bad news, “You have shown me the manure. Now find me the pony.”

I think that we need to look for the gift of these times: an opportunity to improve healthcare delivery, so that we can improve clinical outcomes and cut costs at the same time.  Every one of us who cares for patients can play a role by doing things right the first time and being mindful of what we are doing for patients in the present moment.

At Sentara Health, the acronym SAFE stands for:

• Stop
• Assess
• Focus
• Evaluate

It seems counterintuitive, when we have so many tasks to accomplish, to stop first, but we have precedents.  Before operations, we take time out to verify that we are performing the correct procedure on the correct patient on the correct side.  At most hospitals, we pause to obtain a sponge and instrument count before closing.

Control means different things to different people.  For most physicians I know, control of their time is far more important than control of material assets, like property, plant, and equipment.

The Copernican model of putting patients and families at the center of our universe says nothing about control except that we try to control what we do to patients to cause no harm.  I believe that caring physicians will play a central role and that successful ACOs will coordinate care, optimize outcomes, and limit readmissions regardless of who is in control.

What do you think?

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

Over the summer, as I move to a new residence, I plan to update my ezines.  With this ezine, I introduce you to Ellen Guarnieri, who participated in my ACHE seminar, Practical Strategies for Engaging Physicians.

If you want to learn more about how her hospital improved reliability in the area of cardiac medications, please read on.

Applying High-Reliability Principles to Improve Cardiac Outcomes

Case Presentation

After discussing quality outcome scores for their institution, leaders at a community hospital system decided to take action. Physicians were not routinely following protocol for ordering aspirin (ASA), beta blockers, and angiotensin-converting enzyme inhibitors (ACEI) on admission and discharge. The doctors claimed the data were wrong. Was it a performance issue or a data integrity problem?

A review of the institution’s cardiac medication outcome data showed that the issues were multi-factorial. The organization had set a benchmark for performance on cardiac medication administration at 90% compliance, but composite performance scores were 76%.  The Vice President of Quality voiced concern that despite improvement methods, no movement in scores occurred.

The hospital assembled a team of cardiologists, primary care doctors, nurses, pharmacists, information technology experts, a project leader, and a finance approver. The team set a goal to achieve 95% compliance by the end of the 9-month project cycle. They applied the following five principles of high reliability organizations to their new approach. High reliability organizations* (HRO) are those that can perform relatively error-free, complex operations consistently over long periods of time:

Sensitivity to operations – Hospital leaders assumed that poor compliance with cardiac medication standards was the result of poor ordering practices by the physicians. However, chart reviewers only agreed on abstraction of charted data 42% of the time. They developed standard review procedures for chart abstracters. Physician experts at each system hospital reviewed data and coached individual physicians on documentation accuracy of admission diagnoses to improve data integrity.

Deference to expertise – The team engaged experts at all levels of the cardiac medication delivery system to standardize protocols. Physicians peer-reviewed charts for diagnosis, intervention, documentation accuracy, and protocol compliance. Individual physicians received information regarding their performance and reviewed aggregate data at monthly medical staff meetings. Their focus on correcting care and process issues resulted in improved compliance with evidence-based protocols for cardiac medication administration and improvement in care outcomes.

Reluctance to simplify- The project team employed the Six Sigma process: Define, Measure Analyze, Improve, Control (DMAIC) to solve complex problems. They analyzed data to make fact-based decisions, identified errors and roadblocks, and made changes by piloting solutions. When the team encountered process problems, such as lack of standardization of the patient discharge process, they used a technique known as Work-Out to solve complex problems where the causes are evident. The streamlined discharge process, which included protocols for cardiac medication ordering, was piloted on one nursing unit then implemented hospital-wide.

Resilience – The project manager was responsible for ongoing analysis and reporting of outcome data. A physician council appointed by the Board of Trustees was entrusted with oversight of the process. A monthly dashboard tracked compliance with medication ordering, administration to patients, and chart reviews. The cardiac medication dashboard was incorporated in the quarterly quality report to the Board. Reviews conducted over the next 18 months showed that the process was capable of accurately capturing data, and ongoing focus on the process of ordering and administering cardiac medication showed continued improvement in performance.

Preoccupation with failure: Before the project began, caregivers and hospital leadership accepted defects in the system as physician error. At the conclusion of the 9-month project cycle, the steps of the medication delivery system were streamlined, which led to better information, greater understanding of the care needs of cardiac patients, improved cardiac medication administration, and better relationships between hospital leadership, physicians, and the rest of the care team. The institution exceeded its goal by achieving an overall cardiac medication compliance score of 97.3% by the end of the project cycle, an improvement that they have sustained over time.

Addendum

Although comparisons with other industries have their limitations, the progress that commercial airlines have made in safety over the past 30 years has been remarkable, averaging one fatality per million flights. HRO’s differ from other organizations in that they are able to demonstrate safe outcomes consistently over time. This time-based performance has been attributed to a culture shift present within an HRO. It is the creation of this culture that HRO’s aim to explicitly foster.

HRO’s are organized to acknowledge certain fundamental realities. Chief among these are that teamwork does not come naturally to people and that errors, no matter how much planning is invested for prevention, will happen and that an organization must therefore be prepared for recovery after such events.

Given the key position occupied by physicians in the medical super-structure, if healthcare is to become an HRO, doctors must be a major presence in any culture of reliability. As this case showed, finger-pointing on both sides needs to give way to a data-driven climate of inquiry.

The enabling features of organizations that foster highly reliable teams include:

-  a culture of trust, shared values, safety, and risk-mitigating communication processes

-  communication that provides opportunities for discussion and improvement

-  distributed decision-making, in which all team members share accountability

-  communication that is frequent, specific, accurate, problem-solving, and based on mutual respect

Rather than have safety imposed upon us, let’s start now to incorporate the principles that high-reliability organizations embody.

Ellen Guarnieri has over twenty five years of comprehensive healthcare experience in roles that ranged from staff nurse to CEO of a leading New Jersey Hospital. She is currently the President and CEO of Comprehensive Healthcare Strategies, focusing on organizational planning and redevelopment. Ellen can be reached at Eguarnie@comcast.net.

*Reference

Weick KE, Sutcliffe, KM. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass; 2001.

It was a proud family moment when my son was commissioned as Ensign in the US Navy Friday, May 14, 2010.

The oath of office that he took reads:

 I solemnly swear that I will support and defend the Constitution of the United States against all enemies foreign and domestic; that I will bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the office upon which I am about to enter. So help me God.

My son is living his passion to become a naval aviator.

Well-meaning friends have asked me if I am concerned for his safety. They point to the hazards of an aircraft carrier, where approximately 65,000 pound fully armed aircraft accelerate from 0 to over 150 mph in 3 seconds, launched by catapults, whose controls are set by 20-somethings with an average of 2-3 years experience. And then, there are the landings on a slippery flight deck bobbing up and down, with only four arresting wires to halt the plane.

Knowing that arguing would be futile, I respond, “Sure, any parent would be concerned for his child’s safety. One never stops being a parent.”

But deep down, I feel secure because aircraft carriers embody the five principles of high reliability organizations:

• Preoccupation with failure: focusing on predicting and eliminating catastrophes rather than reacting to them
• Commitment to resilience: assuming that systems can fail in unanticipated ways and learning to contain errors quickly by discussing and practicing responses to systems failures and near misses
• Deference to expertise: de-emphasizing hierarchy to gain input from people with the greatest knowledge relevant to the issue at hand
• Reluctance to simplify: accepting that work is complex and that failures are multi-factorial
• Sensitivity to operations: understanding how processes really work and paying attention to a broad range of factors, such as distractions, availability of needed supplies and personnel, and length of time people have been on duty

Why is healthcare generally not as reliable as aviation? 

As Jack Barker and I discussed in Collaborate for Success!, aviation utilizes organizations such as the Federal Aviation Administration (FAA) to develop and enforce regulations and the National Transportation Safety Board (NTSB) to investigate accidents. Furthermore, aviation has a mechanism through the Aviation Safety Reporting System (ASRS) to report near misses and errors that impact safety. Widespread use of medical guidelines and a process for reporting all medical errors that is not subject to legal discovery are in their infancy.  Healthcare professionals face difficult transitions changing their status from craftsmen to people that value safety and interchangeability.  Distinguishing between iatrogenic injury and complications due to disease often is a judgment journey.

One hospital system journey that gives me hope is the Sentara Safety Initiative which began in 2002 when hospital leaders became frustrated with the pace of change.  Dr. Yates, VP and medical director for clinical effectiveness, wrote that the missing piece was a stronger organizational culture focused on patient safety.  A group of 14 physicians and 2 nurses developed 5 behavior-based expectations (BBEs):

• Pay attention to detail: using the mnemonic SAFE (Stop, Analyze, Focus, Evaluate) to focus attention on the task at hand and decrease skill-based errors
• Communicate clearly, using clarifying questions and repeating back orders
• Have a questioning attitude, empowering healthcare professionals to stop actions when unsure about their safety
• Handoff effectively, using the 5P checklist to ensure successful transfers (Patient/ Project, Plan, Purpose, Problems, Precautions)
• Never leave your wingman, using peer checking and coaching when appropriate

To convert expectations into organizational habits, supervisors provide everyday feedback on BBEs which serve as core competencies on performance reviews. Managers use walk rounds to reinforce safety culture behaviors and make sure that shift-change reports, handoff reports, and pre-procedure briefings are handled appropriately. As in aviation, staff receive encouragement and recognition for reporting near misses and unsafe events. Meeting patient safety goals is a criterion for medical staff reappointment.

Hospital leaders use a system call Real-time Behavior Based Monitoring to monitor overall performance. One quarter of variable executive compensation is linked to achieving safety goals, as is one half of the annual employee gainsharing bonus.

In 2 ½ years, Sentara decreased ventilator-associated pneumonia 84% and device-associated bloodstream infections 63% (Yates GR et al. 2004. Sentara Norfolk General Hospital: accelerating improvement by focusing on building a culture of safety. Joint Commission Journal on Quality and Safety 30: 434-542.). They experienced a 50% reduction in events of harm per 10,000 adjusted patient days system-wide (McCarthy D, Blumenthal D. Committed to Safety. Commonwealth Fund pub. no. 923; 2006:17:165-200).

Sentara has shown that they can enhance culture change by embedding tactical safety improvement projects in a larger organizational strategy. They have promoted a virtuous cycle of organizational culture driving behaviors which drive improved outcomes that reinforce the safety culture and improve reliability.

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

I moved Successful Collaboration in Healthcare: A Guide for Physicians, Nurses, and Clinical Documentation Specialists to the top of my list of books to review because I was intrigued that a nurse would write a guide to collaboration.  As mentioned in  Nursing Collaboration, most of the valuable clinical insights that I have learned have come from interactions with nurses.

I liked what she wrote about communication differences (p.20):

Whereas nurses may focus more on the person and patient knowledge bases, physicians may concentrate on the case knowledge….Although all three aspects may be important when considering the patient’s plan of care, the person considering one set of knowledge may not think the other set of knowledge is as important….Although the physician and the nurse may focus on different aspects, their ability to collaborate for the benefit of the patient should not be affected.

She recommended using the situation, background, assessment, recommendation (SBAR) format to standardize information transfer (p.17).

Ms. Stukenberg’s analysis of the role that physicians and nurses can play regarding financial issues also intrigued me (p.36-37).  For example, reimbursement can nearly double if pneumonia and a urinary tract infection (UTI) that was present on admission cause a major complication in an elderly patient.  Clinical scenarios (p. 107-110) illustrate the importance of physicians and nurses working together, for example when a nurse notes cloudy, foul-smelling urine on admission, contacts the physician to order a urine culture, and when it comes back positive, the clinical documentation specialist makes certain that the chart notes support that the UTI was present on admission.  If not documented properly, payers may conclude that a UTI represents a hospital-acquired condition that they do not need to reimburse.

Ms. Stukenberg wrote that clinical documentation improvement programs are in their infancy and represent a source of competitive advantage for hospitals that are willing to invest in improving documentation and care processes.  Success depends on:

• Hiring the right staff, who are clinically knowledgeable, understand coding and the impact of proper documentation on finances, and know how to communicate with coders, case managers, nurses, and physicians
• Providing the right tools, using a computer program to review charts in real time and match physician documentation with diagnostics (coders can only code off physician documentation)
• Assuring administrative support, especially senior hospital leaders who understand complexity, see the value of their investment, and support the documentation specialists’ credibility when physicians or nurses challenge new processes
• Having a trusted physician advisor who is well-respected clinically, able to explain coding to physician peers on a strategic level, and be a liason when needed to weigh in on important issues
• Educating coding personnel, clinical documentation specialists, nurses and physicians on an ongoing basis
• Monitoring case mix, length of stay, complication co-morbidity(CC), major complication comorbidity (MCC) capture rates,  reimbursement, and effect of documentation on hospital finances 
• Implementing systems to prevent people from reverting to previous habits once their training period ends

 Implications in an era of healthcare reform

I interviewed Ms. Stukenberg by telephone and learned of a number of benefits of investing in improved clinical processes:

• RAC (recovery audit contractors): Being proactive regarding documentation criteria for admission avoids the need to payback money already spent on patient care
• Improving transitions of care: As I wrote in Collaborative Handoffs, approximately 80% of readmissions within 30 days of discharge are preventable
  Reconciling medications, calling  patients within 48 hours of discharge to make sure that they are taking medications as ordered and have scheduled outpatient appointments with their caregivers, monitoring weight of patients with heart failure, and including family caregivers and community providers in predicting home-going needs are all tasks that clinical specialists can facilitate
• ICD10 implementation: By 2013, providers will need to use a more detailed coding system; it is not too early to develop systems that facilitate adoption of the new standard
• Public reporting: in an age of increased transparency and scrutiny, doing processes correctly the first time can improve clinical and financial outcomes and build an organization’s credibility and brand recognition
• Building a culture of collaboration: As I wrote in Collaborative Culture, a culture built by healthcare professionals from the ground up (rather than imposed from above or by outside regulatory agencies) helps to sustain improved clinical processes.

Readers who would like to communicate directly with Ms. Stukenberg can reach her at MCRN@AEROINC.NET.  Her book is also available through www.crcpress.com.

This 113-page book is loaded with practical strategies for improving healthcare collaboration and clinical and financial outcomes.  I believe that it is a must-read for middle-level and senior healthcare leaders in this era of healthcare reform.

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure: I have a material connection because I received a review copy that I can keep for consideration in preparing to write this content.

Dr. Cohn speaking on Physician Recruiting, Contracting, and Retention Strategies

I believe that this Congress of the American College of  Healthcare Executives was the best educational forum that I have ever attended.  Imagine Congress passing major healthcare legislation the same week that over 4,000 healthcare executives met in Chicago to discuss implications of healthcare reform.  I felt that I was part of the present, especially as Mike Fecher and I addressed over 100 people re: Field-Tested Physician Recruiting, Contracting, and Retention Strategies.  I found it provocative that nearly everyone conducted exit interviews of departing physicians to ask why they were leaving, but nobody in the room asked physicians who had been with them at least five years why they stayed and what they could do to make their time more productive.

Some of the many highlights of this outstanding meeting included:

• Maureen Bisognano’s Building Strong Connections Between Cost and Quality, in which she encouraged leaders to “think outside the building,” to improve safety, engage patients in improved self-management, reduce arbitrary individual variation, root out waste, and create a culture that supports the delivery of cost-effective care
• Chuck Mowll’s Best Practices of High-Reliability Hospitals, in which he cited Sentara’s practices of putting red tape around medication dispensing machines to warn people not to interrupt the person using them, using simplification experts to review processes, and encouraging staff to comment on any safety issues that concern them
• Nate Kaufman’s Proven Strategies to Enhance Performance Under Healthcare Reform, in which he encouraged participants to view upcoming challenges as thrills rather than threats as they approached physicians to break even on Medicare by strategic cost reduction, rebalancing payer contracts, recruiting clinical stars, improving coding, revenue cycle, and patient flow, developing an embedded medical group, selectively adding fixed costs, and auditing all financial relationships with physicians
• Ruth Brinkley’s Positioning Yourself for Success, in which she summarized the six ingredients for career success: competence, confidence, courage, resilience, humor, and people
• Gerry Ibay and James Higgins’ How to Succeed as an Early Careerist, in which they described the capacity for deep listening, challenging one’s own point of view to hear others’ perspectives

Although I usually do not stay through Thursday, I was glad that I did this time, to attend Kathleen Bartholomew and Joe Bujak’s Of Lions and Lambs: Transforming Physician-Nurse Communication.  They dressed in costume to role-play disrespectful dialogue and its effect on clinical and financial outcomes, especially in causing people to take out frustrations on colleagues who had nothing to do with the harmful interaction. 

They pointed out that depersonalization protects power and autonomy and that we need to come to know each other as people by celebrating successes rather than focusing solely on mistakes.  When respected physician and nurse leaders come to consensus on behavioral expectations to which everyone is accountable, the majority of those who transgress will apologize and those who don’t will leave.  Safety and clinical quality establish the moral high-ground.

What do you think?

• Does the prospect of healthcare reform make you excited, fearful, or ambivalent
• Can we build a strong connection between cost and quality
• What physician-hospital collaboration do we need to do to break even on Medicare reimbursement
• Do nurses and physicians where you work share behavioral expectations to which everyone is held accountable to improve healthcare communication

As always, I welcome your input to improve healthcare collaboration. 

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

Those of you who read my first book, Better Communication for Better Care, know that stress and burnout figure prominently in my writing because, from my work in 40 states, we are experiencing a tidal wave of stress and burnout in healthcare workplaces.  As Dr. Jonathon Halbesleben, the author of Managing Stress and Preventing Workplace Burnout, wrote (p.xiii-xiv):

Stress has become something of a badge of honor in today’s society…. We are quickly realizing that people who experience stress act in ways that can be problematic for their organizations and for their own well-being.  Over the long term, what starts as a relatively minor complaint can blossom into burnout, lower performance, and even turnover and violence…. If we could help ourselves, stress would not be considered an epidemic….  The goal of this book is to put practicing administrators in a better position to address the stress of those with whom you work.

On page 108 is an interview form that contains questions to ask, including:

• What are the primary challenges you face
• How often do you face these challenges
• What do you enjoy about your job
• What suggestions do you have to make your job better

On the following page, the author writes practical guidelines for facilitating stress focus groups, such as:

• Establish ground rules (for a list of such rules, readers may consult my article on Surgeon Frustration, p. 82)
• Facilitate more than participate
• At the session wrap-up, communicate possible next steps and obtain feedback

I appreciated his answer to, “How can we sustain our work so that we don’t run into future stress-related problems?” (p.75):

• Close the loop
• Continue to reach out and make rounds at your facility
• Retain your team of stress management champions: even as your meetings become less frequent and less intense, they should continue

My only (minor) disagreement based on my experience over the past 12 years was (p.70), “Open-ended questions don’t work with physicians.”  As I wrote in Dealing with a Medical Staff in Crisis, I worked closely with the Medical Staff President to devise a survey instrument that included open-ended questions, such as:

• How would you rate your experience here?
• What is going well for you?
• How likely are you to recommend this hospital to a friend, colleague, or a family member?
• On what do you base your rating?
• What is the future of this hospital?
• What role do you see yourself playing?
• Which obstacles need to be addressed now for the hospital to thrive?
• Whom else should we interview?

Most physicians found the discussions therapeutic, an indication that someone valued their input and validation of their anger and frustration.  Momentum built and physicians who were initially too busy to participate asked why they weren’t interviewed, so I returned about a week later until we had more than 25 physicians’ comments in our database.

Dealing with stress and confronting workplace burnout allow leaders to have an engaged workforce, committed to their organization’s goals and mission as manifested by the:

• vigor that they bring to their jobs
• dedication to advancing the organization’s mission
• absorption in their work, the flow state

Dr. Halbesleben concludes by advising healthcare organizations to acknowledge and deal with stress and burnout:

You have nothing to lose.  You have only to gain a productive, safe organization with engaged employees who stay with you for the long haul- a challenging goal, but one worth pursuing.

I recommend this book because of its practical approach to acknowledge and deal with the causes of stress and burnout. 

What is the situation where you work?

• Are you experiencing an epidemic of stress and burnout
• If so, how are you and your organization dealing with it
• What measures are working

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have a material connection because I received a review copy that I can keep for consideration in preparing to write this content.

For me, understanding physician-hospital relations is a never-ending iterative journey rather than a task with a finite beginning and end.  As I prepare for this year’s presentation to the ACHE Congress (82 x, Physician Recruiting, Contracting, and Retention Strategies, 3/24/10), I recall my first presentation, where I asked the audience, “What is the first thing that comes to mind when you hear the word ‘tool’?”

The most common response was hammer, followed by gun, and then chain saw.  For a number of reasons, I felt fortunate to get out of the room alive.

I can understand the fascination with tools and building a toolkit.  It offers a readily comprehensible framework for the question, “What do you do,” i.e., ”I fix problems.”  We value problem-solvers.  They rise through an organization to become its senior leaders.

For a different way of looking at tools, I salute Chris Warner, who wrote High Altitude Leadership and has led over 150 international mountaineering expeditions.  He lists Danger #3 for high-altitude climbers as Tool Seduction:

Cho Oyu has become such a popular mountain, that the same level of infrastructure that is built on Everest is applied to climbs on this peak.  Each tent is equipped like a hotel room with sleeping bags, ministoves, bags of food, and bottles of oxygen.

Climbers waited for the storm cycle to play out… Precious time was wasted because Sherpas needed to move even more gear into place…. And when the tiny window finally opened, a small handful of us, those not needing all sorts of tools and comforts, snuck to the summit.  The largest groups watched helplessly from base camp.

An overdependence on Sherpas, tools, and infrastructure can limit talented climbers.  Similarly, a parade of consultants packing the latest tools and theories can bog down progress and distract companies from focusing on vital issues.  Of course, tools are important.  But in critical moments, even the best tools break or fail in some other way- yet you must still survive.  The problem isn’t with the tools; it’s in how you relate to them.

Tools offer hope, and they make people feel that they have the right answer.  But a problem occurs when people use tools as crutches for safe answers.  Both dead climbers and dead companies are found grasping great tools.

Act in the face of real fear; subjugate your personal desires to the greater goal of the group; fight arrogance with humility; seek out and nurture partnerships; be seduced by passion and not by tools.

As I wrote in Collaborative Listening, the most important tool for hospital leaders and physicians to grasp is dialogue.  In “Embracing Complexity,” in Better Communication For Better Care: Mastering Physician-Administrator Collaboration, I stated that face-face conversations are the only sustainable way that people can deal with complex situations in which predictability is diminished, experience does not guarantee success, and relationships are key.

 Physicians can help because our training prepares us to make major decisions based on limited information.  When lives are at stake, we often do not have time to obtain perfect information and have to rely on our clinical intuition.  Act-learn-adapt, or as we say in surgery, “Ready, fire, aim,” characterizes clinical practice.

What do you think?

• Do we use tools as crutches
• Are there tools other than dialogue that improve physician-hospital relations reliably
• Can you fathom extensions of act-learn-adapt into administrative situations

 As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.