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Wednesday, June 27, 2012

Put Your Personal Mark On Your Work

Have you ever thought about the impact you make on others as you do your work?  Someone is usually watching, how you do what you do, if not up close, from a distance.  Over my career, I have been amazed at what team members have done for customers on their own, without prompting, to create excellent experiences for the customer.  This takes two things in my view to accomplish:
  • the right CULTURE

CULTURE:  Some organizations have a culture that allow their team members to "make it right" no matter what.  Team members do not fear making a mistake.  The culture is blame free.  The organization looks at systems problems, and knows that few issues are bad people problems.

EMPOWERMENT:  is a difficult concept to embed in a culture.  It can be offered from top leadership, but the team members has to step forward and accept it and act on it.  A team member at a PALS Hamburger Stand in Johnson City, TN is faced with a customer at the drive-thru that doesn't have quite enough money to pay for the order that he placed.  The team member has to make a business decision.  He/she decides using judgement to say "That's fine, just pay me the next time you come by here."  The customer is astonished!  The team member is fearless of punishment for potentially losing money on the sale.  The manager will reward the team member for providing excellent customer service.  This type of "Sudden Service"  has helped to earn PALS Hamburgers, a very small hamburger chain the Malcolm Baldridge National Quality Award!

I asked my team members, who all worked in an Emergency Department, what they did on their own, outside of the standard customer service training to put their personal mark on their work.  Here are some of their answers:  
“I am careful to make eye contact with every patient so that they know I am giving them my attention.”
“I put a blanket over and under every elderly patient to preserve their body heat.
“I tell seriously injured patients that they are at (name of hospital), and that they are safe now”.
“I keep patients informed and carefully explain their treatment to them.”
“I turn the TV to the education channel, when it can help them.”
“I tell the patient that it has been my honor to care for them.”
“I use fun bandaids or decorate them!”
“I always sit down when I talk to my patients”
“I like to use warm blankets and footies and change them whenever they need to be to keep the patient comfortable.”
“I remember to put my name on the white board.”
“I keep a bag of angels.  I wear one, and pass them on when I’m asked about them.”
“I ask the patient about their family, pets, etc. to personalize the relationship.”
“I go visit the patient when I am assigned to A side and they have been moved to B side”.
“I teach the patient about taking their BP – right size cuff, and make sure they understand their medications.”
“I give patients a foot massage if they have had a long wait”
“I spend as much time as possible using comfort measures, propping patient.”
Maintenance: “I touch up paint every week so that scuff marks don’t build up.”

One of the best examples of an employee making their personal mark is Johnny the Bagger

At one job as a leader I started receiving cards and letters about a particular employee who was a Paramedic.  I saw him one day and I asked him what he was doing differently.  He scratched his head and said, I really don't know.  All I can think of is that when I go visit the patients the next day in the hospital they seem glad to see me.  Paul hadn't realize that his act of kindness in looking up his patients and visiting them was something above and beyond what his patients expected him to do.  They remembered his name and were so impressed they felt compelled to recognize him.
We have all had excellent customer service experiences where we could tell that the person serving us was doing something unique that was not part of their job description. 
My challenge to you is to find that special thing that you can do for others that will WOW them.  I have made just a few suggestions below.  Please comment and give me your best ideas back.
  • When in your office with someone and the phone rings, don't answer it.  Give the person in your office your undivided attention.
  • Ask your team members about their family.
  • Be more visible.  Round for Outcomes.
  • Have lunch with your team members.
  • Empower someone to do something they didn't know they could do.

Tuesday, June 26, 2012

Keeping Up

Today I had the privilege of delivering a lecture to a large class of Critical Care Paramedic Course attendees.  These folks are probably not going to get a raise for gaining the extra training, but they are adding additional tools to their toolbelt to be able to be put in use for their sickest patients.  They patiently listened as I went over the required curriculum and a couple of case studies that I added in.  Much of the information was a review of content they had in Paramedic school, but for some that had been years earlier.  I had no problem praising them for taking the time to learn more and to prepare to provide a higher level of care.

No matter what job you have, the body of knowledge surrounding that job continues to evolve at a rapid pace.  It is all of our individual responsibilities to pick ways that we can KEEP UPWhat Got You Here Won't Get You There: How Successful People Become Even More SuccessfulMarshall Goldmith is the best-selling author of "What Got You Here, Won't Get You There".  What a great title to remind us that we have to be life-long learners to continue to be effective.  Whether you are a Paramedic facing an ever sicker population of patients requiring transfers to other facilities or you are a leader facing newer HR problems like FMLA Abuse, Social Media Violations, etc.  We have probably all known clinical care providers and leaders who were stuck in the past.  In fact, it takes years for evidenced based medicine to become commonplace practice.  I am very interested about Change Management when providers, given scientific evidence resist change.  But let's face it, some people don't even get exposed to the evolving science, they just remain stuck in the past.  For change to occur, these people have to retire or go work for the competition.

Here is my top 5 list on why to KEEP UP:
  1. If you are in a mission critical field, someone's life may depend on it.
  2. You will continue to enjoy your job more, if you don't experience knowledge gaps when everyone else is moving ahead of you.
  3. You will be a more valuable resource at work if you can contribute recent advances and best practices in your field.
  4. It doesn't sound good in court if an expert witness says you are behind the times in your practice.
  5. Job Security
My hat truly goes off to those that will take the time to stay abreast of changes within their field.  Today, it is very easy to stay connected to relevant and useful information.  I'm going to list a few, I know each field has it's own list.  Whatever you use, no matter what field you are in, thank you for taking the time to KEEP UP!

  1. Google Scholar - very useful resource for finding scholarly articles.  Most of the time you get access to the full article.
  2. CEU Online Courses - great web based content.  Some professional associations provide these for free.
  3. Join a professional association.  Networking opportunities with other members is very valuable.
  4. Attend professional meetings.
  5. Obtain specialty certification.
  6. Attend professional conferences.
  7. Read professional journals in print or online.
  8. Pursue a higher degree.

Horst Shultze, President of Ritz-Carlton Hotels said in a presentation I attended, "Don't compare yourself to others in your field, you could end up being the best in a group of poor performers!"  He was cautioning us as a group of hospital personnel to be careful using comparative benchmarking because the whole industry could be underperforming.  He challenged us to compare our processes to proven excellent processes such as an Indy 500 Pit Crew.  With that same spirit, I challenge you, to not compare your training needs to your peers.  Think about what you need to be a finely tuned instrument of excellence.  What training will prepare you to close the gaps that are present in your co-workers.  As for me, my recommendation is that you prepare yourself in three basic areas:  Technical Skill - Teamwork - Customer Service
  • Technical Skill - in most workplace environments, this will get you by.  If you are highly technically skilled, people will excuse your lack of ability to play as a team member or your poor customer service and say "Oh, that's just Bob."  In my teams, it takes all three to be a good team member.  As far as KEEPING UP, courses to enhance your technical skill are important.  Your must keep sharpening the saw.  But, do us both a favor and address the other two dimensions.
  • Teamwork - No one likes to come to work and see someones name on the schedule and moan.  Just about all workplaces involve teams.  The days of the Lone Ranger are over.  If you have a deficiency in this area, attend some training in team building or maybe your workplace can have a retreat on building your team.  Working as a team is important.  I know these are overdone, but:
    • Together Everyone Achieves More
    • There is no "I" in TEAM
  • Customer Service - Everyone is your customer.  The person that pays for your services is your customer.  Your co-worker who depends upon your work output is your customer.  Now that much of our industrial complex has moved out of the country.  The U.S. is mostly a service oriented country.  If you don't like customer service, get used to it.  Police officers now do community policing with a connection to the community, hospitals are reimbursed based upon patient satisfaction scores, the oil change guy rushes to get out to meet me as I pull up.  Everyone's expectation of service is extremely high.  If expectations are not met, complaints and in the case of medicine, legal action quickly ensues.
Do a self assessment and round out your training plan.  Best wishes for your lifelong journey toward learning excellence.

Monday, June 25, 2012

Lead From the Front

I have always had a practice of not asking my team members to do things I would not do.  Now, let me clarify.  I frequently ask my team members to do things that they can do better than I can do.  I have had people working under my direction on the organizational chart, but the skill and ability they had to do their job, far exceeded my ability to do their job.  Yes, I am a nurse and a paramedic, but if you are a trauma victim, at this point in my career, where I spend most of my time managing or leading, you want someone else on the org chart drawing your blood and pushing the your meds.  The leadership key is that your team members know who you are and know that you would be WILLING, IF NOT ABLE to do the very work they are being asked to do.

Today, while rounding in the hospital kitchen, as I entered the dishwashing line I saw an employee and her supervisor working together washing dishes.  The employee assigned to do dishes was by herself with a moving line of breakfast dishes.  Her supervisor, has some choices:
  1. Stay in his office and try to call for someone to call in to help.
  2. Move another employee from another prep area and make that area short
  3. Roll up his sleeves and work

When assigned to lead other people, it's hard to do your management duties and also do the work, but many times the right thing to do is to LEAD FROM THE FRONT.  When the ED got very busy, I sometimes went to triage and triaged incoming patients.  An example is set that our leader is willing to pitch in and help us. 

I like the television series "Undercover Boss".  It highlights company CEO's who have rarely been seen outside of ivory towers that wear a disguise and rotate some of the more routine jobs of the company.  Invariably, the CEO learns pearls of wisdom from the frontline employees who are generating millions for his company. http://www.cbs.com/shows/undercover_boss/  Leaders need to find a way to be more familiar to the front line.  I use taped video messaging of my hopes for how we provide service and my expectations for our team members.

I've not been in the military, but I think the military understands leading from the front.  Troops have to be led into battle.  All the supervisors can't just stand back in a safe place and say "OK guys, go get em!" 

If that is true, what are the behaviors we as leaders need to exhibit, when we are leading from the front:
  1. Knowledge of the Plan
  2. Resource Person
  3. Calmness Under Pressure
  4. Technical Skill
  5. Teamwork
  6. Excellent Customer Service
We are to be role models as leaders.  If you let your guard down and laugh at a demeaning joke, or you allow rule-breaking in your presence, you need to remember -- WHAT YOU PERMIT, YOU PROMOTE.

A closely related skill to leading from the front is the skill of delegation.  Here are some do's and don'ts for delegation:

  • delegate tasks that can be done better by someone else.
  • delegate tasks that will develop another person.
  • delegate tasks that are repetitive in nature.
  • delegate things that you just don't want to do.
  • delegate things that you are not willing to be responsible for if mistakes are made.
Leaders can be more effective when they get things done through others.  For more information about delegation, see:  http://www.businessballs.com/delegation.htm

“Lead from the front — but don t leave your base behind.”
Nelson Mandela

Tuesday, June 19, 2012

Can I Really Trust You?

This week I've been thinking a lot about those around me and how much I value the ones that are totally truthful. Over my career, it has been interesting to me that leaders sometimes surround themselves with people who continually tell them what they WANT to hear instead of the what they NEED to hear. As for me, I prefer to know the truth, the whole truth, and nothing but the truth. Where have I heard that before?....Oh yeah, the courtroom.

In one of my early management jobs, I went through a battery of tests administered by two Industrial Psychologists from Tulane University named Gig and Irv.  Following the tests, the gave me feedback on the results.   There were several deminsions on the tests that I showed very good balance on, but on one demension I was off the scale.  The two men looked across the table at me at said this will be a problem for you.  It's the "Honesty" scale.  I asked how could that ever be a problem to be honest.  Before the movie ever came out with Jack Nicholson saying the famous line "You can't handle the truth!".  Gig and Irv explained to me that in organizations, complete truth telling is not always valued.  At some level, people had rather not know certain problematic things that are going on, that are difficult to solve, or that involve those that are difficult to deal with.  There have been times in my career when I have heard Gig and Irv whispering in my ear, complete honesty will be problematic for you.

Complete trust on the other hand is required for teams.  Patrick Lencioni, in The Five Dysfunctions of a Team said that trust is the foundation of being a functional team.

The absence of trust is the biggest problem in dysfunctional teams.  According to Lencioni the main problem here is the tendency of group members to show vulnerability.  It is our tendency to show ourselves as invulnerable in the workplace.  A retreat to work on trust-building might work to expose some of those vulnerabilties.  Simple things such as discussing each persons Hopes and Fears for the teams future and discussing some personal things about each other that is likely unknown by other members of the group.

For the most part, healthcare is a team sport.  Consider the paramedic.  He or she must be able to trust their partner to watch their back on a gang shooting scene as they bend over to care for the patient.  The nurse on the floor must be able to trust the ER nurse to give accurate information in report. Rebuilding trust if failures occur in these areas if very difficult to do.  But it all starts with showing vulnerabilities.

If you decide to have a retreat to deal with trust, their are a variety of games and exercises that purport to build trust available on the internet.  A professional facilitator may also be able help to bring the group together.

One of my greatest successes was when I was assigned to supervise both the Inpatient units and the Emergency Department.  Historically, the Inpatient units are accused by the ED as holding empty beds and delaying taking new patients.  The ED is accused as being pushy and providing incomplete reports.  So, we brought both groups of Charge Nurses together.  Everyone introduced themselves giving professional and some personal information.  Following that, everyone participated in some group training on Communication as an inservice for Charge Nurses.  Then, they broke up into small mixed groups and rotated among stations to design new processes.  What resulted was better understanding between the groups, and the Inpatient Units began to "pull" patients out of the ED.  What a success when each group understood the other's issues and were able to see each other as trusted colleagues.

Wednesday, June 13, 2012

Being Out Front

What does it take to be innovative?   Most people find it pretty hard to be at the front of the pack.  Everett Rogers in his description of the Diffusion of Innovation described Innovators as VENTURESOME and says that only 2.5% of the population of any defined group will be able to carry that load.  It is really hard to truly be on the cutting edge, to be creating the new evidence for the rest of us to follow.  It takes a risk-taker to throw some caution to the wind and be inventive. 

"Results!  Why, man, I have gotten a lot of results.  I know several thousand things that won't work."
                                                                                              -Thomas Edison, U.S. inventor (1847-1931)

What do we remember about Edison?  Do we remember that he was a bumbling scientist that tried a lot of things that didn't work.....no, we remember his success.

I actually am happy though, when I can get my team to live in the next segment of the Bell curve.  Being an Early Adopter is not as easy as it sounds.  A new idea comes out, let's even say that it is evidenced based by one of our good Innovator colleagues.  I would like for my team to be part of the 13.5% of the population of a given group that will actually go ahead, take a risk, and follow the evidence.

In healthcare it takes an inordinately long time for change in practice to occur.  I have seen examples of 10 years and more of best practices not being adopted in healthcare.  And yes, some health care providers have to stop practice before certain procedures will change.  It is hard to keep up.  Providers today would have to constantly read journals or have computer alerting systems to keep up on the current science.  For those that have to retrain in CPR or ACLS, they know that every 5 years, the American Heart Association is going to make an evidenced based change, and they just get prepared to make the change.  Everyone is sort of forced to become Early Adopters.   Rogers said that Early Adopters were RESPECTABLE.   If you are now trying to label your teams, here they are:

Early Majority folks are DELIBERATE.  They are just a little conservative and want to see others be successful before investing time or resources.

Late Majority people are SKEPTICAL.  About everything.  Enough said.

Laggards are TRADITIONAL.  16% of the population of any group hold onto the past.  They don't want to make a change even when the evidence says that new new way is better.  This one I don't understand.  When we all went to school, did we get the impression that history was going to stop with us, changes would not occur?

Using my best Jeff Foxworthy imitation, I'm going to give you a test...

  1. If you don't know how to turn on a computer, you may be a LAGGARD.
  2. If you think that you should not have to have any additional training for your job, you may be a LAGGARD.
  3. If you are asked if you tweet, and you make bird noises you may be a LAGGARD.
  4. If you have your neighbor's 12 year old add contacts to your phone, you may be a LAGGARD.
  5. If you are assigned to move a project forward at work and you make any of the following suggestions before making a decision, you may be a LAGGARD.
           A.  Re-run the data one more time.
           B.  Re-analyze the data data one more time.
           C.  Go on a site visit to see how someone else handles the situation.
If you have more laggardisms, please send them in comments!

So, what is the fix?  The fix is to have a Standard Planning Process.  Once your team members get accustomed to a lot of their questions being answered up front, they will be more comfortable with their followership.  Look at the tool located at:  https://www.mc.vanderbilt.edu/root/vumc.php?site=intranet&doc=35158

Expect Resistance and go review my blog on Executing on Change.

There is value for your customers and pride for your team when you head toward the front of the pack.

Monday, June 11, 2012

Catching People Doing Things Right

It seems that much of my time is spent putting out fires.  When I can remember to just walk away from the numerous e-mails and issues of the day and round for purpose one of the best parts is seeing the good work that is going on. 

Many leaders round with an eye toward what is wrong in the workplace.  That is a responsibility of every leader.  However, a major opportunity is missed when we fail to Reward and Recognize excellent performance.  As leaders we can leverage excellence by calling it as we see it and letting our team members know that we appreciate them.

I like to round like Quint Studer suggests.  Round for Outcomes.  Seek out the High Performers and spend time with them.  Remember, your time = love to your employees, just like to your kids.  Low performers tend to eat up time, but you can change that.  The High Performers deserve your time.  Talk to them, see what is going well, what needs to be changed, what systems need improving, then thank them and walk away leaving the low performers wondering why you didn't ask them. 

Here are favorite ways to reward and recognize:
  1. Send a personal note to the employees home.  E-mails just don't have the same impact.
  2. Give movie tickets or dinner tickets to teams that perform well.
  3. List people in a newsletter who the managers harvested from rounding that are very helpful, or even let team members nominate each other for being helpful or for service excellence.
  4. Post comment cards from customers.


  • Reward and Recognition does not have to blow the budget.
  • None of us get recognized enough for our contributions.
Rounding for Outcomes:  http://www.studergroup.com/newsletter/Vol1_Issue1/roundingforoutcomes.htm

Friday, June 8, 2012

Making Better Decisions

During the Great Depression, Herbert Hoover said "I'm tired of making decisions one after another all day long.  My view of Heaven is of a place where no one ever has to make a decision."(1930, Fairchild)  Decision-making is tough.  We always have critics to comment on our decisions.  We all are decision-makers in our own lives, and some of us are entrusted with decision-making on behalf of others or our companies.  The problem is, there is a great deal of evidence that we are not that good at it.  IF, however, we can push pride and ego out of the way for a moment, "decision-making prowess is a skill that can be learned (2002, Russo & Shoemaker).

Research shows that the less competent people are, the less likely they are to know it.  Overconfidence is a deep seated human characteristic.  Drunk drivers are absolutely convinced that they can drive.

Decision-makers without the skill to resist also fall for confirmation bias - the tendency to favor evidence that supports our current beliefs and to dismiss evidence that challenges them.

Some quick fixes:
  • Rely upon participation in the decision-making process.  This generates widespread buy-in when it comes time for implementation and allows more ideas to be tested.
  • Adopt challenge up / support down with your team.  Create a culture allowing your ideas to be challenged.  Once a final decision has been made, everyone agrees to support the decision down to the subordinates.

If you admit for a moment that you could possibly be a bad decision-maker, you join a pretty prestigious group:
  • "That idea is so damned nonsensical and impossible that I'm willing to stand on the bridge of a battleship while that nitwit tries to hit it from the air" - Newton Baker, U.S. Secretary of war in 1921 failing to recognize the impact of air superiority in warfare.
  • "Heavier than air flying machines are impossible." - Lord Kelvin, British mathematician, physicist, and president of the British Royal Society, spoken in 1895.
  • "A severe depression like that of 1920-21 is outside the range of probability." Harvard Economic Society, Weekly Letter, November 16, 1929.
  • "I think there is a world market for about five computers." -Thomas J. Watson, chairman of IBM, 1943.
So how do we do with major life decisions?
  • 63% of people killed in car collisions are not wearing seat belts.
  • Peer pressure follows our decision-making through life.  We have to have the
    • latest game
    • drink the coolest drinks
    • get married when our friends do
    • have kids because our biological clocks are ticking
    • buy bigger houses
    • buy a boat
  • Decisions about marriage in our society
    • The divorce rate in America
      • for first marriage is 41%
      • For second marriage is 60%
      • for third marriage is 73%

So it's obvious that we need some of those skills that we can learn to make better decisions.  Russo & Shoemaker in Winning Decisions presents such a tool as a Decision-Making Process:

  1. Framing
  2. Gather Intelligence
  3. Learn from Experience
  4. Come to Conclusions

Framing is looking at an issue like looking at an iceberg.  Realizing that there is always much more under the surface than you can see.  Snap decision-makers fail to take into consideration confounding variables that are impacted by their decisions.  When you are presented with a new issue, whether consciously or unconsciously, the presenter frames the issue in a certain way.  It is important to remember that taking the time to look deeper will bring you to more options and to better decisions.


Once the frame is large enough to see the issue, the field for gathering intelligence can be identified.  A great decision is made only after relevant facts can be considered.  Teams working to come to a decision need more than just their own minds, they need the intelligence of people affected by the decisions.  They need to know about the marketplace, the competitor, the best practices, the innovators.


   The next step is consulting those with experience in the issue at hand.  Generally, I am not wild about consultants.  They come talk to me, put what I said on PowerPoint and present it back to the organization with an invoice.  But.....what they do bring is the experience of being in several organizations and learning from others what is working and what is not working.  Rather that using pure consultants, I like to find colleagues who have lived through an innovation or change process and visit them or speak with them about what worked and what pitfalls to watch for. 


  I love the story about the blind men describing the elephant by describing the part they were touching.  Coming to conclusions may feel that way.  Once going through a process, any process, coming to a conclusion feels more organized and can be bought into.  This process is reviewing and narrowing of options.  Time may be spent on determining a criteria based tool to guide the final decision.


Decision by Consensus gets a lot of credit where I have worked.  This is when issues are discussed among experts until there is broad agreement on a course of action.  Agreement does not equal action.  A real change occurs when there is a critical mass moving forward with implementation.

Wednesday, June 6, 2012

Communication: Can you Hear me Now?

Shannon and Weaver in 1949 diagrammed the communication process.

Why should such a simple, well known process cause us so much problem?   Studies has shown that communication delays and failures cause hospitals to lose $12 billion annually, or 2 percent of their average annual revenue.  A 500 bed hospital could save $4 million annually by improving communications (MD Business Gazette 3/09).   
Communication of operations data to those that can impact the data is paramount to operations improvement.  Yet many of our systems make it hard to have that simple task happen.  Supervisory personnel must be committed to making part of every day about communicating with their personnel.  3 questions...What is going well, What is not going well, What can we improve on.  To do that offices must be left unattended, shoes must be put to pavement, phones have to be dialed, meetings have to be cancelled.

Clear expectations have to be communicated.  Every worker must know what are the things that are truly expected of them.  We all talk of transparency.  Transparency really needs to be around the elimination of agendas around how we are judging performance.  We are adults, it's time for open bood tests.

A novel concept around communication is to think before you communicate.  There are 4 types of relevant thinking to communication:
  1. Facts - what are the key points to be communicated.
  2. Form - is the communication likely to be best received in detailed accuracy or sequences of information.
  3. Free Thought - best for creative ideas, start ups, innovation
  4. Feelings - It takes people skills to communicate.  Excellent communicators are trained in customer service and morale building
If possible, during those difficult communications, it is great to communicate from a position of shared values.  What do we all agree on.  On September 9, 2011 we all argeed on patriotism.

So what are the failure points at communication.  Here are a few:

  1. Failure to consider other perspectives.
  2. Choosing the wrong communication method.
  3. Responding defensively.
  4. Failing to share information.
  5. Failing to be direct.
  6. Breaching confidentiality.
  7. Failing to listen.
(adapted from:  

How do you respond when a new team member approaches you and says, "Hey, when I was in Ft. Worth, we did it another way."  Most of us bristle up and want to respond "You ain't in Ft. Worth anymore."  The fact is that the varied experiences of our team members can help expose us to best practices or different practices that no one at our organizations have experienced before. 

I attended a conference several years ago and became very excited about a new concept in how to handle triage patients with a physician working alongside the triage nurse.  I came back and reported to the entire team, sent slides to everyone, the whole deal.  The idea went no where.  A few months later, my physician colleage went to a different conference and heard the same speaker give the same presentation.  At that point, there was immediate buy in.  So sometimes, the messenger counts.  Physicians may hear better from physicians, ED nurses from ED nurses, Police officers from police officers, and so on.

What communication improvements can your team make today?

Tuesday, June 5, 2012

Learning from Adverse Events

With a 30 year career in healthcare, largely with a bend toward preventing harm coming to patients, I thought it was rather odd, when on February 24, 2011, I found myself arranging a transfer of my 76 year old father to the tertiary referral center ER that I worked in following failed treatment at a capable community hospital.  He arrived in Septic Shock.  Within a few hours we knew something that the community hospital knew 5 days earlier but had failed to share.  My dad had MSSA.  Methicillin-Sensitive Staphylococcus Aureus.  Not the bad kind of staph.  The good kind that responds to antibiotics.  But a series of broken systems prevented a phonecall from being made to my family advising that immediate antibiotic therapy was warranted, and in his case, since a painful replaced knee joint had brought him to the ER, a surgical washout was indicated.  Despite an immediate surgical washout of all of his joints and aggressive antibiotic therapy, he died within 2 weeks of multi-system organ failure.  My dad, a preventable death, that one would hope has led to significant system changes to prevent that type of error from occurring again. 

Since 2001, it has been known that safety systems in hospitals ranked right up there with bungee jumping, extreme mountain climbing, and motor cycle racing (Amalberti 2001).  We tend not to think that our life is taken into our hands when being cared for in hospitals but remain cautious about ultrasafe systems such as scheduled airlines and nuclear power.  Hospitals have inherent dangers of complicated technical equipment, extremely sick patients, infection sources, a hurried staff, delays in treatment, unclear orders, and mislabeled specimens (The Advisory Board Company (2005).  We forget that even small chances of error add up to high numbers of adverse events every year.

Efforts have been underway since the mid 2000's to address the feared 100,000 lives being lost at the cost of preventable medical errors.  Hospitals have now started focusing for example on holding physicians and nurses responsible for handwashing.  Something Florence Nightingale published in 1915.  Change is not coming easy to gain compliance.  Health care workers are subject to the same resistance to change that all adult workers are.  To make matters worse, 100,000 lives was a low number.  "The death toll from health-care screwups adds up to at least 500,000 Americans annually.  That is the equivalent of more than three jumbo jets crashing every day of the year." (2012, Graedon)

Health care workers do tend to be high achievers and pay attention to data, especially when it is drilled down to their own data.  We can learn from Adverse Events.  Here is a top 10 list....

  1. Investigate fully all adverse events - identify the etiology of serious medical events.  This is the first step in eliminating mishaps.
  2. Look for trends.  Time of day, provider/nurse/ unit specific data should be analyzed.
  3. Prepare cause & effect diagrams (fishbone diagrams) involving people involved in the event

4.  Study and address root causes ( look at day and time, categorize common causes,
5.  Study impact of patient behavior (intoxication, mental illness, anger)
6.  Look for communication errors  (blood culture results!)
7.  Keep emphasis on quality improvement, not blaming.
8.  Widely disseminate findings, where you cannot share case results, provide general education.
9.  There is no margin of error that is acceptable.
10.  Your staff does not GET THIS...until you make it personal.  Here is my dad...

10 WAYS PATIENTS CAN PREVENT MEDICAL ERRORS (From:  (2012) Graedon, J. and Graedon, T.  Top Screwups Doctors Make and How to Avoid Them.

  1. Expect mistakes and have an advocate with you in the hospital.
  2. Check every medicine.  Make sure the dose is right.
  3. Be assertive.  "Being nice can get you killed."
  4. When in doubt, say no.  Demand an explanation.
  5. Be vigilant during transitions, from one floor to another, or when shifts change.  Handoffs in care are risky.
  6. Alert the nurse or "rapid response team" if something seems wrong.
  7. When discharged from the hospital, get detailed instructions and contact information.  Know what symptoms might signal a worsening situation or infection.
  8. Hospital doctors may never speak to your primary physician.  Take your records and don't assume doctors already know what's in them.
  9. Double check everything.  Don't assume no news is good news or that test results are always correct.  If something seems wrong, request a repeat.
  10. Take a friend or family member to doctor's visits.  Nearly every error made in the hospital can also be made in the outpatient setting.  A second pair of eyes and ears can be very useful in getting instructions and spotting problems.

An Infection, Unnoticed, Turns Unstoppable: The Story of Rory Staunton

Executing on Change

It is a fallacy to think that change is managed.  There are too many dynamics operational around a major change to manage.  However, change can be successfully implemented even in the face of naysayers and those who would build coalitions against a change that is critical for your organization. 
You can always count on death, taxes, shipping and handling, and CHANGE.  One reflection I like to make is how often Charles Darwin is misquoted about the survival of the fittest thing.  He actually said "It is not the strongest of the species that survives, nor the most intelligent that survives.  It is the one that is the most adaptable to change."  Survival in an organization or a family, for that matter requires adaptability to a myriad of situations.  Those that don't change are bound for extinction! 

I like to coach managers that work with me that their role in change execution is LEADING THROUGH CHANGE.  They must keep their eye on the goal and be unwavering in that.  The path to get there is negotiable, but the getting there is non-negotiable.  A lot of stock is put in having visionary leadership.  Thomas Edison says that "Vision without execution is hallucination".  So I put all my efforts into EXECUTION.

What are the first moments like to your team when you announce a change....John Kenneth Galbraith says that "faced with the choice between changing one's mind and proving that there is no need to do so, almost everybody gets busy on the proof."  Your team is unlikely to embrace change right out of the gate.  Your expectations should be realistic.  A wide range of emotions will flood among your team.  A friend of mine, Tom Hornsby in his book New Roles for Leaders (2000) written with Larry Warkoczeski points out that you should plan for resistance.  Here are the phases:
  1. Business as usual - Be Happy!  (Denial)
  2. Threatened and Angry - What's Happening to Me?
  3. Create a coalition against change - What's happening to Us?
  4. Create Obstacles - They're not getting away with this!
  5. Destroy Success - Kamikaze mentality
So, what do you do, to execute successfully?

There are great tools available and you may need professional help.

My two favorites, I offer here:

The Complex Change System Component Effect shows in each box what is required for a successful change effort.  The output shows what happens if one piece is missing in the required elements.

My most favorite tool is the Standard Rollout plan.  Employees can handle the change better if they were involved early on in the design, they have the relevant evidence with regard to the need for the change, and the process is well planned.  This tool can be found at: 
or downloaded from pages.
"Become a student of change.  It is the only thing that will remain constant"  Anthony J. D'Angelo