Rather have a book, or an e-book?

Tuesday, July 31, 2012

People First

Many organizations use five or six pillars to represent the supporting structure of their organization resting on top of a firm foundation.  Those pillars may include Service * Quality * Finance * Growth and a combination of other supporting principles, but will almost always include the People Pillar.  In an article today in Wharton at Work titled People First, Strategy Second a book by Ram Charan called The Talent Masters (Crown Business, 2010) is highlighted.  In the book, he highlights the importance of investing in people and identifying those with growth potential.  The best companies in the world have learned that it is best to recruit from within.  Senior leaders are heavily involved in recruitment at all levels, new talent is observed for in the ranks, judgements on leaders are based upon hard evidence and cross-checking by observations by multiple people, leader development is as aggressive as delivering financial results.

I have heard all my life that the church is not a building, it is the people that go to gather in the building.  Many organizations forget the their very organization is made up of the people that work there. 

I have always said that the patient is my first priority, the second is the people that care for the patients.

This guiding principle has helped me through many decisions.  The first time you say that to a group of employees, they don't like it.  They want first place.  But when you explain that no one would work the night shift if the patient was not in first position, it begins to make sense.  It has been equal for me to the Ritz-Carlton's "We are Ladies and Gentlemen serving Ladies and Gentlemen."  It does say to me how I think employees should be treated.  I think they should be treated the way I woud want to be treated.  They are a valuable resource.  They should be carefully selected.  My friend and author Tom Hornsby wrote in his book New Roles for Leaders that leaders should H.O.G. (Help Others Grow).  I have been repayed many times over for spending extra time with people to help them learn something new.

The balance of course is accountability.  People have to be accountable for their actions.  The more clear we make our expectations, the easier it is to hold people accountable.  If an individual understands their role and chooses not to perform their job, they should expect that they would be held accountable for that.  If they are dishonest, they should expect to be be held accountable for that.  Remember, I have talked about 2/3 team members and low performers.  Leaders don't have to be drill sergeants, they have to be coaches and scorekeepers.  If you have tried to coach someone and they cannot do the job, it becomes a matter of self selecting off of the team.


You owe it to your other employees to hold those not pulling their weight accountable.  Remember, the chances are, lower performers will bring other employee's performance down to their level.


So how do we identify those hidden talents out there?  They are watching you.  They are trying to do a great job and hoping that someone is noticing.  They are not negative, but they may make helpful suggestions.  They would be great to serve on a committee to get a particular task done.  They are people that you could delegate additonal tasks to and they would not even think of complaining - it would be a reward to them.  They would be happy to learn more and do more.  If they need more skills, you might need to invest in some training, or at least suggest what training they need.  Promoting from within is a great idea.  People who work their way up have great stories to tell.

Monday, July 30, 2012

Customer Service in Healthcare

I've given you some tools to help you provide excellent customer service, but let's review a little bit about the basic concepts of why customer service has a place in healthcare.  Earlier in my career, there were debates in the professional literature about whether "patients" were really "customers".  That always seemed strange to me.  Except those patients who are severely ill or injured, patients exercise choice.  Therefore, they enter into a customer supplier relationship with healthcare providers.  There should be no doubt in anyones mind now that payors are beginning to reimburse providers based upon those customer satisfaction ratings.  We care what customers think and must understand that their perceptions of quality differ from our perceptions of quality.  More importantly, healthcare providers have to learn and understand that perception equals reality for the customer.  Your employee may not think he or she is rude, but if the customers think that, the employee has something to work on.

Perception = Reality

To help employees appreciate how others perceive the services they receive, it is important that they see the data that is collected.  Posted trend charts of satisfaction surveys should be readily available.  The data should be discussed in staff meetings.  It is good for employees to have some education on what customers expect.  They want the same things that the employees want when they are customers:
  • to have some control
  • respect and dignity
  • fair treatment
  • friendly, warm, caring service
  • to feel safe and secure
  • honesty
Employees who help develop strategies for superior customer service are more likely to follow through with those strategies:
  • exceed customer expectations
  • demonstrate empathy
  • fully discuss alternatives
  • follow through
  • keep promises (promise low, deliver high)
When a customer complains they have needs as well:
  • to be taken seriously
  • immediate action or reaction
  • someone to be punished (customers are rarely gratified on this one)
  • to be listened to
  • acknowlegement of their feelings
  • followup
Data shows that customers who have filed complaints and recovery was handled well are more likely to return for more business than those who never filed a complaint.  However, their are pitfalls to handling complaints:

  • defensiveness
  • citing policies
  • poor listening
  • passing the buck (we are busy)
  • over reaction
  • siding against the organization
There are many strategies to improve customer satisfaction, but if you were the Ritz-Carlton, that would be setting the bar too low.  What you really want to do is to build LOYALTY.  You want customers who will always return to you for service.  The equation to do that sounds simple.  You need to build relationships and deliver zero defects.

When I think about my own customer experiences, the fact is, I have chosen places where defects are at a minimum.  I get very consistent technical service.  So relationships count very high.  You think along with me:

  1. I have been seeing the same dentist for years mainly because he is on my insurance plan and both he and his hygienist are friendly to me.
  2. I go to a dry cleaner that does not have a drive thru window (inconvenient), but every employee calls me by my name.
  3. I go to the same Mexican restaurant because every server knows to bring me both cheese dip and guacamole dip.
  4. My neurologist always brags on my headache log and reminds me to call her if I need anything.
Organizations can nail the quality side, but without relationships they still will not be able to build customer loyalty.  I cannot emphasize too much that having satisfied customers does not mean you will be building your customer base for repeat business.  With healthcare facing a shrinking dollar, LOYALTY will be the phrase of the future.  Organizations will be looking for ways to separate themselves from the competition.

Ritz Carlton Credo

The Ritz Carlton Hotel has a simple concept for it's employees to follow:  "We are Ladies and Gentlemen serving Ladies and Gentlemen."  Within that short sentence is embodied the concepts of respect for the customer, service, and respect for it's own employees.  It is a formula that works setting the Ritz-Carlton apart as a service leader.

Saturday, July 28, 2012

Giving Feedback

Giving feedback is an important leadership skill.  High performers deserve our praise because we constantly need to be "re-recruiting" them to our team.  If we fail to do that, they will be successfully recruited to someone else's team who knows how to reward and recognize.  Personal thank you notes, movie tickets, bonuses, or simply a few minutes of your time telling them how much they mean to your team will go a long way.  Remember, people don't leave organizations, they leave managers.

Lower and middle performers are also in need of your feedback.  The most compassionate thing you can do for someone who needs to improve is to tell them so.  If they are not doing well, your unhappiness with them will affect how you interact with them.  They will be unhappy as well and their performance will continue to suffer.  Let me give you several examples.

"That's just Mary"

When I hear of an employee's behavior that is unacceptable and someone tries to defend their behavior by saying "that's just the way they are", words of my psychology professor ring in my ear.  All behavior occurs because it worked for that person in the past.  Some employees have developed a pattern of bad behavior that has been tolerated over the years.  No one has cared enough about the person to bring it to their attention.  Yes, you heard me right.  No one cared enough.  I was rounding in a new area of mine once and I observed an employee being very rude to a new co-worker.  When I asked the manager about that, I was told, "That's just Mary."  My confidence level in the manager for dealing with the situation was very low.  She had just accepted Mary's behavior failing to realize the impact Mary was having on employees new and old.  Mary had to have a plan of correction.  When I spoke to Mary and told her my concerns, she became tearful and told me that no one had ever told her that she was perceived as loud and rude.  What a disservice we do to colleagues when we don't share with them how people feel about them.  People cannot improve if they are not given an opportunity to know what needs to be improved.

I wouldn't want him working on me!

An employee who lacks the technical skill to excel on the job needs to have that feedback.  In healthcare, we tend to eat our young instead of build them up.  That strategy is not helping us to meet the challenges of the aging population and the need for more healthcare workers.  Our turnover rates are over 20% per year.  We need to be about building skill in a mentoring way.  Training programs of all types are not always effective at turning out persons completely skilled in all areas.  When we encounter an employee who is struggling, the most compassionate thing to do is to provide the feedback and design a way for the employee to skill up.  The most exciting way for employees to do that in healthcare is through simulation.  The newer technology allows employees to practice their skills in a safe environment simulating the real environment without putting patient safety at risk. 

John is great technically, a great team member, but he is terrible with customers!

My friend Julie Kennedy would refer to John as a 2/3 team member.  People tend to excuse him.  He is dependable, a rock star technically, he just has one flaw.  He pisses people off. (excuse the frankness)  John is a complaint generator.  He is gruff with patients but they all want him to start their IV because he is so dang good at it.  He works 60 hours a week so just about everyone is afraid he will quit.  The doctors all love him and refer to him as a supernurse.  But as his leader, you know that you are having to clean up after him all the time.  He is a 2/3 employee.  John needs that feedback.

When you sit down with John, his arms will be crossed as if daring you to say anything negative to him.  But as a leader, you have to provide the feedback.  The feedback is this.  You need the full package out of everyone.  He is great at teamwork, and he is technically skilled, but his customer service skills are lacking.  You need him to improve.  People in the department think he is a good nurse, but you classify him as a 2/3 employee.

All of the air will be sucked out of your office.  A wide range of emotions could be exhibited.  But it has been my experience that John will either address the concern, or he will self select to another workplace where he is not held accountable for customer service.

Source:  Julie Kennedy: The Studer Group


When preparing to give feedback think about how to handle various responses.  What would you say if the employee had any of the following responses:

  • Denial
  • Anger
  • Requests Help
  • Attacks another employee's performance
  • Attacks your performance
  • Tries to change the subject
It is good to practice in advance with someone else who can help you plan your responses.  Decide how you will "stay on your message."


For complex issues, a followup discussion should be planned.  People who have been given feedback will be wondering how you feel about their performance in a week, a month, and so on.  New issues should be addresses as soon as possible.  You can't change other people, but they can choose to change themselves.  If that is accomplished, they need to hear positive feedback from you, the successful leader who did not ignore the problem.

Friday, July 27, 2012

Have High Standards

Everyone likes to be on a winning team!  The only winning teams I have ever heard of are those with very high standards for themselves.  Our facility just went through a week long Joint Commission visit.  One of my areas was so ready for the inspection that they were a little disappointed that they didn't have a thorough review.  They knew they were up to the standards of the Joint Commission, but more importantly, they were up to their standards for themselves.

In an earlier blog, I discussed the phenomenon of people in a group lowering their performance to the performance of the lower performers in the group.  This is a leadership problem.  What is permitted is promoted.  It is demoralizing for employees to see others get by with substandard performance.  Why should one member of the team work their butt off when everyone else seems to be slacking off through the shift.  To prevent this from occurring leaders must either reward the higher performers or be actively working on the performance of the lower performers. 

During my worklife I have actually had co-workers ask me to slow down or change this or that, because I was making them look bad.  The peer pressure usually forces conformance to lower standards. 

When I round on employees I like to give them an opportunity to show me their best work.  For nurses taking care of 3-4 patients, I might say, which one of your patients will tell me what EXCELLENT care you are taking of them.  The nurse is free to steer me away from someone if they wish, but almost always they say, "I'm taking care of these patients talk to anyone you like!.  With a Food Service employee I ask them "What do you think I should sample today"?  Environmental Services, "Show me how great you have cleaned a room."  Putting a positive spin on rounding makes the encounter with the staff member enjoyable, but there is still no doubt that you are there to check on how things are being done.  When things are not up to standard coaching can be implemented.

When employees talk to each other, they are proud to be on a team that has high standards.  They are proud when they are being measured and they see the scores come up.  As leaders we have to put the data in front of the employees and give them the tools and best practices to help them excel. 

Insanity: doing the same thing over and over again and expecting different results.

Albert Einstein

When a team is stuck and cannot reach the standards set for them, the problem is usually one of not making a significant change.  Here is what I have seen:  Mediocre performance is occurring time point after time point.  The leader comes before the group and announces, "we are not doing as well as we can, please try harder."  Nothing significantly changes so the mediocre performance continues. 

I believe strongly that you cannot improve something that you cannot measure.  A run chart is a simple way to look at data but a control chart explains why mediocre performance continues.  When a process (even a bad process) is in control (i.e. within upper and lower control lines) that process will stay within control unless acted upon by a change in the process itself.  No amount of encouragement to try harder will make the change occur.

Once a significant process change occurs you will see sequential points above or below the center line and the upper and lower control limits will need to be recalculated.


The key point is that achieving high standards is unlikely without process change.  Leaders must have the skills to identify entrenched processes and lead through changing those processes to ones that demonstrate measureable improvements. 

Once the team experiences success with this a few times change comes easier and easier, but making changes is not for the faint of heart.  Review the June 5 blog on "Executing On Change".

So let's think for a minute about the alternative.  If you lower your standard just a little bit, how would that play in other industries.

IF a 1% error rate was acceptable....
6 drug errors per hospital pharmacy would occur per day
870 airline crashes in the US would occur per day
20,000 wrongful convictions would be made per year (The real error rate is 0.5% 0r 10,000) !
200,000 patients would have wrong site surgeries performed each year (The actual rate is 0.00000893)

So 99% may sound like having high standards, but it is really not that high.  When we are the customer, we want everything done correctly every time.  As leaders we have a responsibility to put systems in place to drive the error our of our processes.  As stated in an earlier blog, variability is the enemy of quality.  Looking back at the control chart, you will notice that as variability decreases, performance improves, and the control lines reset.

One of the most consistent teams that I have seen work is the Level I trauma team.  Upon a 5 minute notification, the whole team assembles in the trauma bay and suits up with protective apparel.  A chart on the wall used to teach new members shows where each team member stands and what they are supposed to accomplish.  When the patient rolls in, the airway is verified, the patient is moved to the emergency department stretcher and team members all around the patient quietly and competently work to assess and save the seriously injured patient.  The patient is sedated, intubated, blood is administered, an x-ray is taken, an ultrasound is completed and the patient is readied for transport to CT Scan or to the OR depending upon their injuries.  All of this happens, day after day, consistently in 17 minutes.  I have seen other teams work with disorganization, raised voices, and frustration. 

Seeing this team work demonstrates several points.  A high functioning team can come together from different disciplines and meld together in an instant if everyone knows the protocols, if the standards are set high enough that everyone knows the expectations and are commited to meeting those expectations, if there is a clear leader that is in control, and finally if the team has sufficient volume to act together to remain practiced.  That last point is important.  Much has been written in the last few years about minimum volumes of certain procedures that should be done by physicians for them to be competent to continue doing them on patients. 

Any team works better when it is well practiced.  In those circumstances where your team may be called upon infrequently to complete a critical task, it is your responsibility to conduct drills so that some "muscle memory" develops that can be called upon when the real thing happens.  Part of that is quizzing your team to see if they remember the steps to take if a particular event occurs.  Having high standards means being ready for any eventuality.  When I was in Johnson City, we were a primary trauma center for a nuclear fuel depot.  We had to have the staff ready 24x7 to use plastic and paper to wall off the emergency department to be able to accept nuclear contaminated patients.   Formal drill once a year, yes, but keeping everyone knowledgeable about what that big cart was with huge rolls of paper, etc was a constant chore.  Pressing toward the highest standard requires constant engagement from the entire management team.

Thursday, July 26, 2012

Ethics & Professionalism

Thanks for coming back!  I appreciate the Worldwide Audience.  ;-)

When we see someone in our field acting in an unethical or unprofessional manner we feel like our own reputation is being affected by the other person's behavior.  That is guilt by association.  When we see people act badly it makes you wonder why they got involved in the healthcare field.  Most people in the healthcare field started out wanting to help people.  Many find their role in helping people to be a calling, not a job.

Ethics is from the Greek "ethos" meaning "character".  It's the discipline dealing with what is good and bad and with moral duty and obligation.  Webster's says that ethics are the principles of conduct governing an individual or group.

Our ethics get tested in the workplace due to our rapid pace, too many priorities, our work/life imbalance, poor leadership, poor interpersonal communication, and a staggering workload (Boyd, 1997).  The results of this can yield physical and psychological reactions, sleep loss, headaches, weight loss or gain, and panic attacks.

Professional Behaviors:

  • Integrity - consistent honesty, ability to complete assignments
  • Empathy - showing compassion and respect for others
  • Self-Motivation - taking initiative to improve or correct behavior, not requiring constant supervision, accepting constructive feedback
  • Appropriate Appearance and Personal Hygiene - clothing neat, clean, and well maintained.  Good personal hygiene.
  • Self-Confidence - Exercises good personal judgement, awareness of strengths and limitations.
  • Communications - Speaks and writes clearly, listens actively
  • Time Management - Consistent punctuality, completes assignments on time.
  • Teamwork and Diplomacy - Placing the success of the team above self interests, not undermining the team, remaining flexible and open to change.
  • Respect - Being polite to others, not using derogatory or demeaning terms, not behaving in a manner that brings discredit to the profession.
  • Advocacy - Not allowing personal bias to interfere with actions you take with people.  Protect and respect other peoples confidentiality and dignity.
  • Careful Delivery of Service - Mastering and refresing skills, performing equipment checks, following policies, procedures, and protocols.
  • Tolerance - Ability to accept people and situations.
  • Functions under Stress - Maintains professional composure in stressful situations in spite of inappropriate actions on the part of others.
  • Attitudes:  Is actively concerned about others, maintains a positive outlook toward others and toward assigned tasks.  Recognizes and admits mistakes.  Seeks and accepts feedback and uses it to improve performance.
           (Source unknown)

Unprofessional behaviors have become such a frequent problem in adverse event analysis that The Joint Commission released a Sentinel Event Alert on the Subject in 2008.  Read the entire Alert Here

The Joint Commission Sentinel Event Alert

Issue 40, July 9, 2008

Behaviors that undermine a culture of safety

“Intimidating, disruptive behaviors can foster medical errors, contribute to poor pt satisfaction and preventable adverse outcomes, increase costs…. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.

Have you ever heard that "the bad apple can spoil the barrel".  Individuals who chronically display bad behavior can impair the whole groups functioning.  (Felps, W. et. al 2006)  It is much more likely that the low performer will bring the groups performance down to their level than the group will be able to lift the low performer up.  It is critical that the leader deal with the low performer.

Disruptive behavior creates a culture of fear, confusion, apathy, burnout, distrust of leaders, errors, and communication problems. (Pickert, Jim)

There are great courses on how to deal with "special colleagues" who create disruptions in the workplace.

When you go about your work, who are you trying to please?  Does a supervisor have to oversee everything you do?  Do you take personal pride in the work you do?

Colossians 3:23-24

"Whatever you do, work at it with all your heart, as working for the Lord, not for men, since you know that you will receive an inheritance from the Lord as a reward."

I try to do the best I can at whatever I am asked to do.  Not every task I have is fun, but most are necessary.  If someone has to do it, it might as well be done well.

Early in my career, I noticed that others were watching me. (No, I'm not paranoid)  As an EMT responding on an emergency call, people watched my every move, that was understandable.  On a routine call, they watched how I cared for their family member, what I said, how carefully I drove.  As a nurse, my peers watched how I handled pressure situations.  Was I cool under pressure?  Families and patients watched my every move.  I learned that a smile was reassuring.  In leadership, I learned that team members needed to have confident but compassionate leaders.

As you are being watched in whatever role you now have or aspire to have, remember to pay attention to your ethical and professional foundation.  People will remember those things about you and come to depend upon your consistency in those areas.

Note:  Special thanks to Jackie Ashburn and Jim Pichert for assistance with content for this posting.

Wednesday, July 25, 2012

Take a Look at the Forest

You Can't See the Forest for the Trees!

Has anyone ever said that to you?  Ever thought about what it really meant?  It means when you are in the middle of a forest, you can't appreciate it, because all you see around you everywhere is....trees.  In many healthcare environments today, all we can see around us are trees. 

There is work to do everywhere and shrinking resources to accomplish the work at the high standards we have set for ourselves with which to guide our practice.What's all this talk about high standards?  We do a lot of very costly things in healthcare that are not evidenced based although facilities such as the one I am working at have been moving rapidly in tools to accomplish just that, we still spend the majority of  healthcare dollars in the final months of a person's life, we have instant access to amazing imaging, etc.

The other cliche that comes to mind is that when we step back far enough to see the forest we need to see, and help our team member see, THE BIG PICTURE.

For healthcare to start making more sense, every person in every job role as to see their place in the big picture.  The healthcare organization's largest expense is labor including salary and benefits.  Each employee whether full time has to begin to see where they fit.  Let's just talk handwashing for a minute.

Now I really go waaayyy back here.  I actually remember when we did not carry latex gloves on ambulances.  In fact, when HIV was identified in the early 80's and universal precautions was recommended by the CDC, there was a backlog on getting latex gloves for ambulance services.  The only gloves we had on our units were in the OB kit, and if you used those, you had better come back with a baby! 

But really, 2012, and we don't have this one nailed yet?  Everyone on the team has to step back, see the forest, and realize that they are the potential vector of a deadly infection when they come into contact with an immunosuppressed patient.  Every person entering and leaving a hospital room must wash their hands.  As leaders, we have to identify how to show people the big picture.  Here are some ideas:

  1. Announce it in a staff meeting - worst idea.  Nobody is listening to you in a staff meeting.  Seriously, do you remember how bad retention is during a lecture session.  Best estimates are that people only remember 10% of what they hear.
  2. Do a demonstration - a little better.  People remember about 20% of what they see and hear.  Handwashing is a good example.  You can show them how long a 15 second hand wash is and how to get between the fingers and to get the nails good, oh and don't forget to turn off the water with the paper towel.
  3. Have the employee do a return demonstration - now you are talking.  People will remember 30-40% of what they hear, see, and immediately apply.  Here is where you have to be a leader.  No joking around.  They really have to demonstrate competency.  No shortcuts.
  4. Now that you are up to the 40th percentile, if you want better performance, the hard work really begins.  You, the leader, have to INSPECT what you EXPECT.  Remember, your team members are lost in the trees.  You have to continually show them the big picture.  This is not about numbers.  This is about lives. This is about their role in the healthcare system.  You have to observe on a regular basis to see those numbers come up.

I talk to a lot of people who are stuck at about the 1/2 way point of compliance.  Usually what's missing is leader attention to detail.  Our employees are busy with the trees.  They must have the leader articulate on a regular basis that whatever is being measured is important and is part of the big picture.  Further, the employee has to be able to connect with the big picture.

One phenomenon that I am interested in with the attention on evidenced based practice is how hard it is for nurses and physicians to change practice.  In our rollouts, we have presented the evidence and found that even in the face of strong evidence compliance seems to be more related to pressure from leadership than knowledge of the evidence.  To me, it should be enough to know that hourly rounding by nurses decreases falls, decreases call light use, and decreases pressure ulcers.  However, to get these tactics hardwired, it took management presence on the unit on an hourly basis observing for the hourly rounding to be done.  Our knowledge of what needs to be done and what is done is conflicted when in the midst of the trees.

Recently, nurses were surveyed and it was found that nurses had widespread job dissatisfaction.  It is frustrating to feel that you cannot get accomplished all of the tasks you know you need to accomplish.  So, it is possible that adding management pressure is simply confounding this situation and causing those items with measureable outcomes that we feel are important to improve while something else has to be left undone.  This idea needs more study.  However, as our very funding now is dependent on performance on identified metrics, it is likely that we will be continuting to measure and have to perform on those metrics.  See what metrics are important to your hospital because they are 1) publicly reported metrics and can drive patient choice and 2) are affecting payments from payors at:  http://www.hospitalcompare.hhs.gov/

Outstanding performance is possible.  I am proud and amazed at the Vanderbilt Adult ED Nurses.  Since April 2005, they have scored at the 100th percentile (i.e. best in the nation) for courtesy and respect shown toward the patient and family member.   This translates to over 67% of their patients marking Excellent when asked that question.  20% mark Very Good, 2% mark Fair, and 2% mark Poor.  Even being the best in the country doesn't mean that you can't improve in some areas.  Horst Shulze, President of Ritz Carlton said that you should not compare yourself to others in the same business all the time.  You can end up the best of a group of poor performers.  For example, if you are trying to be the best at a turnover process, study the Indy pit crews.  They know how to change all the tires, refuel, and get the car back on the road in seconds!

Right now, one of my departments, Environmental Services is working to improve a score on:
Patients who reported that their room and bathroom was "always" clean.  Our score is 67 with a State average of 72 and a National average of 72.  This one score is adversely affecting our hospitals funding.
It is fairly important that leaders in this area, help the team members see the big picture.  As is the case with any team, for scores to move up, everyone has to be rowing in the same direction.  The ability to see the forest helps greatly for everyone to have the perspective to do the right things right..

Tuesday, July 24, 2012

Be Thankful for Bad Bosses

As you develop your leadership style, you will do well to watch other leaders around you.  From those excellent leaders take those traits that you admire.  If you admire their coolness under pressure, file that away for some time when you are involved in a pressure situation.  If they are the best rounder that you have ever met, become like them.  Invariably though, we mere humans have faults.  We all do!  As you develop your own leadership style you have the opportunity to note those faults in the leaders around you and to simply say to yourself, "when I am in a leader role, I'm not going to do that"

When you sit back and think about mentors that you have had, don't leave out the bad ones.  I actually learn quicker from my mistakes than from my successes and I have noticed that I can learn effectively from the mistakes of others.  The worst boss that I ever had is a man that I must be thankful for.  To the extent that I know how important it is to make a connection with people, I have to be thankful for how it made be feel that he never made a connection to any of his employees except the ones in his family.  I saw how favoritism existed in the workplace and that gave me a strong sense of how importance equality and fairness were to my own values.  We were in a regulated business and I watched as he cheated on inspections.  His lack of integrity spoke volumes.  As a boss, I don't think he taught me one single thing TO DO, but he taught me hundreds of things NOT TO DO. 

When you are involved in the depths of struggles with overbearing or psycho bosses, you can do one thing.  Take mental notes of what not to do when, and if, you are in a leadership position. 

Beware of the Psycho Boss

A 2011 study reports that bosses are 4 times more likely to show psychopathic tendencies when tested than the general population.  This has been interpreted to be indicative of their lack of empathy and remorse for their actions making them well suited for their rise to the top.  This is not to say that there are not quality, well balanced people in leadership positions.  As you take a look at political, religious, organizational, law enforcement leaders you will see examples that you may not want to emulate in your own personal leadership style. 

You know what you like in a leader.  I've blogged about what I think is important, but you and I probably don't agree upon everything.  Decide what you like about the leaders around you and begin to do what they do.  Meet with the ones you really admire and see if a mentoring relationship would be acceptable to the both of you. 

I wish I were there with you, but as I list some random leader traits, who do you think of?  Which of these traits do you want for yourself and for your team members to experience from you as a leader?

  • Honest
  • Competent
  • Will step on others to get to the top
  • Inspiring
  • Condescending
  • Just
  • Dependable
  • Partial
  • Responsible
  • Aggressive
  • Compassionate
Adapted from

Your career as a leader will last for your entire worklife.  Whether you are a leader by title (positional authority) for you are an informal leader, the traits you develop will be seen by others and emulated.  Yet another reason to consider what character traits you exhibit. 

Check out this webpage for a review of Leadership Styles

Monday, July 23, 2012

Do you have the equipment to do your job?

Kudos to my new environmental services director Shane Fulford.  When he asked his employees if they had the equipment to do their job, they all looked down.  Not at the floor in disgust, but at their heavy, hard to push, no longer lockable, stainless steel cleaning carts.  The fix was not hard, but had to be recognized, and paid for.  $450 durable plastic cleaning carts.  You should see the smiles.  We all have to have equipment and tools to do our work.

For some of us, we have to have the iPhone or iPad and the latest app to be able to prepare the best meeting minutes.  I remember when we had strict policies on what job positions merited the use of a cell phone, wait a minute, those were bag phones. 

Our job frustration can climb and climb if the basic equipment we need is not made available for our use.  Police officers need patrol cars and working radios.  Firefighters need protective apparel.  The problem is, as leaders we have to make tough decisions about what is affordable in an area where there is an endless request list of equipment and supplies available for purchase.

"Gadgets come from the fertile imagination of a practitioner, are delivered to the greed of the entrepreneur, who have sold the devices without proper research"
                                                                 -Paul B. Magnusen
                                                                    -From the 1938 Scudder Oration
                                                                       "Fundamental versus Gadgets in the Treatment of Fractures"

Given the need of healthcare organizations to limit spending in anticipation of financial cuts from Medicare and Medicaid dollars, healthcare leaders cannot invest in "gadgets" without demonstrated returns on investment.  As revenues per patient visit/discharge go down, expenses per patient visit/discharge must decline as well for healthcare organizations to remain solvent. 

During budget meetings I've been in the middle of a lot of catch 22 situations.  You have to spend the money to create the additional revenue.  However the equipment is so expensive, it takes years to see your return on investment.  Funding is never sufficient to meet the needs.  In many healthcare organizations, equipment purchases get down to patient/staff safety issues before the dollars can be released to make the purchase.  Let's look at a few examples.

1.  Item:  Cleaning carts
     Useful Life:  5 years
     Years in Use  10+ years
     Cost to replace $450 each ($10,500)
     Comments:  Locks are broken
     Regulatory Issues:  Unsecured chemicals
     Safety Issues:  Child Hazard, Suicidal patient hazard

2.  Item:  Replacement of Cardiac Monitor/Defibrillator
     Useful Life:  5 years
     Years in Use: 12 years
     Cost to replace $12,000
     Comments:  Cable sockets not longer working.  Cannot get a clear reading.
     Regulatory Issues:  Undependable equipment
     Safety Issues:  Patient Safety

3.  Item:  Disaster Mobile Tent
     Useful Life:  5 years
     Years in Use: New
     Cost:  $ 3400
     Comments:  Will allow for continued operations in the event of facility loss.
     Regulatory:  Addresses disaster planning

Imagine you have been given a list of 20 items!  OK, we will just talk about these 3.  If you were just given an equipment budget of $15,000 some tough decisions would have to be made.  Do you risk putting off purchasing any disaster equipment for yet another year?  Do you buy some cleaning carts and plan on buying some each year until you eventually eliminate the hazards.  Is item 2 an obvious must have? 

We haven't even talked about capital (usually over $3,000 - $5,000) and non-capital equipment.  The approval processes on these items are totally separate.

In any case, leaders are supposed to be asking the question, Do you have the equipment you need to do your job?  When the answer is no, leaders are to try to make something happen.  Sometimes it is to borrow, sometimes it is to lease, but hopefully it is to provide the tools necessary to do the job.

My hat goes off to the LifeFlight Communicators. They constantly track the position of ground and air ambulances and coordinate a million details.  Do they need equipment to do their jobs?  Just as much as the Environmental Services tech that is keeping our patients and staff safe from a deadly infection.  They both need the appropriate equipment and tools to do their job.

I have gone into some work situations, where the equipment and tools needed were some modest creature comforts.  A break room, a microwave oven, a coffeee maker.  Maybe this fits under "Respect for People" more than "equipment", but a need is a need.  When I am trying to build rapport with my team members, I always want to know about what they need to do their jobs, even if it just to make their break time more of a real break from work.  In one of my prior jobs, the employees had assembled a break room right in the middle of the action area of a busy Level I trauma center.  The designated break room was like a ghost town.  The employees could grab something fast and get back to their patients.  It was a true win/win.  This became integral to the design in the Vanderbilt "A" pod.  The break area is 12 feet from the trauma rooms.

The Marco equation says that Happy employees equal happy customers (Nelson 2010).  Small things such as the temperature of their workspace or having to work on an ailing computer can become big things if left unattended to.  More on questions I ask when I round on employees later.....

Wednesday, July 18, 2012

Integrity is Integral

in·teg·ri·ty   /ɪnˈtɛgrɪti/ [in-teg-ri-tee] 


1. adherence to moral and ethical principles; soundness of moral character; honesty.

2. the state of being whole, entire, or undiminished
In previous weblogs, I have talked about honesty and ethics, but the word integrity really brings it all together.  A character trait that leaders must possess is one of integrity.  Disney teaches their employees (excuse me "characters" to be "on stage" in front of the public and to be "off stage" only when out of view.  For leaders, integrity is a 24 hour a day gig. Our consistency in decision-making sets the tone for our leadership style.  It determines whether others feel they can depend upon us or not.  This is one of the most important factors in retaining employees.  It is said that people do not leave organizations, they leave their managers (Buckingham & Coffman 1999).

If you are feeling the need to do some personal development of integrity.  Check these 10 Steps out:

1) Identify aspects of your behavior that require change. Reflect on your interactions with others in the workplace, at home and in social situations to determine specific areas in need of improvement. For example, if you are late for work every day and feel guilty about creating excuses for this behavior, this may be an opportunity to develop greater personal integrity.

2) Determine your reasons for not behaving with greater personal integrity. For example, you may be pushing unpleasant work tasks on to other employees instead of being honest with your boss about your inability to do the tasks. You may be afraid to admit to yourself or to your boss that you do not possess the right skills or that the job is not the right fit for you.

3) Face the obstacles that cause you to lie or violate your moral code. This might involve finding a more suitable job, facing your fears about how others may perceive you and/or seeking out counseling to address emotional challenges and insecurities.

4) Practice truthfulness. Consider all of the relationships at home and work that will benefit from greater truthfulness. For example, if managing a team of employees, be honest and direct with each individual about your expectations and employee performance. Avoid backbiting or gossiping.  Refrain from causing harm. Part of developing personal integrity is gauging when and how to deliver the truth. Be careful not to confuse truthfulness with anger-driven and brutally honest confrontation.

5)  Make a list of tasks and behaviors in which you will become more trustworthy. The list might range from basic tasks, such as taking out the trash as promised to repaying large sums of money in a timely manner.

6) Respect the property of others. Consider any complaints you may have received in the past about using another person's belongings, parking in someone else's parking spot or littering on another person's property. Make a concerted effort to respect other people's belongings.

7) Listen to and respect the opinions and decisions of others. Part of possessing personal integrity is acknowledging the human rights of others. Respecting diverse thoughts and decisions is a sign of open-mindedness and integrity.

8) Help others in need. If you are in a position to contribute to the development of others or help them to do something they cannot accomplish on their own, make an effort to assist.

9) Assess your progress. Developing personal integrity is a trial and error process that requires persistent effort. Ask yourself on a daily or weekly basis if you are making progress.

10) Enlist the help of others. Colleagues, relatives and friends who know you well and have your best interest at heart can assist your progress by providing objective feedback on a daily basis about the personal changes you are making.


Can organizations have integrity?  Do you remember ENRON?
Stakeholders lost billions of dollars when accountants and board members turned their backs on corporate misdoings.  Retirement funds were lost forever.  The lack of transparency in business dealings with power residing only in a privileged few led to the disastrous consequences.  Larger organizations have corporate integrity programs, most with hotlines to report suspected wrongdoing or compliance officers.  Federal whistleblower laws protect and in some cases incentivise those who expose curruption.

In what ways to Healthcare Organizations behave with integrity?

  1. Operate within compliance with state and federal laws and regulations.
  2. Follow proper billing procedures.
  3. Follow generally accepted rules of accounting and use outside accounting services for auditing.
  4. Provide for appropriate separation of duties when handling money.
  5. Follow its own policies.
  6. Follow appropriate bid processes according to policy.
  7. Avoid even an appearance of special favors or partiality between the organization and vendors.
  8. Treat employees fairly and equitably.
  9. Use only qualified providers of services.
  10. Train employees in compliance.

What Employees Want....

Quint Studer wrote in Hardwiring Excellence that employees want to find PURPOSE, to have WORTHWHILE WORK, and to MAKE A DIFFERENCE.  In prior blogs, I have connected how different job roles are all critical to the provision of healthcare.  Healthcare is a team sport.  If any team member is removed, the absence is missed quickly.  I have recently dealt with some issues where some of my employees are not feeling valued by other team members.  That is really sad.  Every member of the team has value and should be reminded of their importance. 

The Gallup organization provided a list of what employees wanted in a workplace. 

  1. to know what is expected of them
  2. to have the materials and equipment to do their jobs correctly
  3. to have the opportunity to do their best every day
  4. to receive recognition or praise for doing good work
  5. to have a supervisor or someone at work that cares about them as a person
  6. to have someone at work that encourages their development
  7. to have their opinion count
  8. to have the mission/purpose of the company make them feel their job is important
  9. to have my co-workers committed to doing quality work
  10. to have a best friend at work
  11. to have someone at work talk to them about their progress every 6 months
  12. to have opportunities at work to learn and grow

Notice that in this list, pay did not make it into the top 12.  It's not that pay is not important.  Employees are just telling us as leaders that there are so many other things within our control that are important besides compensation.  Good supervision means paying attention to these things not just waiting for the organization to adjust pay levels.

I have never believed that anyone comes to work to do a bad job.  If there are performance problems with an employee, it exists because that behavior has worked for them in the past.  For it to change, someone must address it.  For most employees, to have them experience worthwhile work, making a difference, and purpose in their work, it starts with excellent leadership incorporating concepts from the Gallup list above.

Thursday, July 12, 2012

Back to the Basics

How many fields of business right now are calling upon their masses to get "BACK TO THE BASICS"?  Healthcare is.  Nursing is calling for hourly rounding on patients, more handwashing, and falls prevention.  Medicine is calling for better access to primary care, less reliance on expensive high-tech testing, and improved communication between doctor and patient.  Medicare is penalizing hospitals for hospital acquired infections, low cleanliness scores, and poor pain management.  For years, we have been learning to be high tech when the patient in all of us has been crying out for high touch. 

Florence Nightingale sent letters to nurses in training at St. Thomas Hospital between 1872 and 1900 on how they should practice as nurses (Nightingale 1915).  In those letters, she gave us many of the basics of patient care. 

"When we obey all of God's laws as to cleanliness, fresh air, pure water, good habits, good dwellings, good drains, food and drink, work and exercise, health is the result.  When we disobey, sickness."

I am now working with Environmental Services, Food Services, and Patient Transport Employees.  They don't realize that they are just as much heroes to the patients and family members at the medical center as the very doctors and nurses providing care.  Let's think about that.

Environmental Services:  Florence Nightingale herself spoke of the importance of cleanliness and good dwellings.  The government is adjusting reimbursement based upon hospital acquired infections.  EVS team members are critical to a hospital.  Everyone notices trash that is running over, body fluids not attended to, and a kind word from any member of the hospital team that enters a patient's room. 

Food Services:  You can look at my picture and know that food is important to me, especially when I'm stressed.  For patient's and family members it is important as well.  Food is a challenge in the hospital environment or in any institutional setting.  But back to Florence.  She talked about the importance of food and drink.  I am reminded of chicken soup when you have the flu.  It is so important to have that right thing that you can eat when you are able. 

Patient Transport:  I worked at a facility where a patient transporter was getting thank you notes all the time.  I finally asked him what he was doing that was special.  He beat around the bush for awhile and then confessed that he always introduced himself and called patients by name, OK that was expected, and then he revealed the magic.  For little old ladies, when he went by the blanket warmer, he stopped, got a warm blanket and wrapped their cold feet in a warm blanket.  Almost 100% of the time they would ask, what was your name again?  He had that special thing he did for people that made him enjoy his job and made the patients enjoy him. 

It's not that high tech is not important.  It is so exciting that today, if I start experiencing signs of a stroke, I can get rushed to a hospital and have an interventional radiologist snake a catheter into my brain and using fluroscopy can find the exact location of the clot and infuse a clotbusting drug directly on the clot, break it up and my stroke symptoms can resolve!  Wow!  Not that many years ago, I would have been a gonner.  Patients and families though continue to tell us that they judge us based upon what they know, not what we know how to do.  They don't know all that technical stuff.  They know the basics.  Did we smile at them?  Were we friendly?  Did we keep them warm?  Were they kept informed?  Was their environment clean or was there evidence of the prior patient left in the room?

We are judged on what the patient DOES understand.

Thanks to one of my long-time colleagues, friend, and now blog-readers, Jackie Ashburn for bringing to my attention the work of Robert Fulghum who wrote "All I Really Needed to Know I Learned In Kindergarten".  See his web site at http://www.robertfulghum.com/.  Now that is back to the basics!  He says that wisdom was not at the top of the graduate school mountain, but there in the sand pile at preschool.
So let's check out his wisdom and apply it to our workplace:

• Share everything.
• Play fair.
• Don't hit people.
• Put things back where you found them.
• Clean up your own mess.
• Don't take things that aren't yours.
• Say you're sorry when you hurt somebody.
• Wash your hands before you eat.
• Flush.
• Warm cookies and cold milk are good for you.
• Live a balanced life - learn some and think some and draw and paint and sing and dance and play and work every day some.
• Take a nap every afternoon.
• When you go out in the world, watch out for traffic, hold hands and stick together.
• Be aware of wonder. Remember the little seed in the Styrofoam cup: the roots go down and the plant goes up and nobody really knows how or why, but we are all like that.
• Goldfish and hamsters and white mice and even the little seed in the Styrofoam cup - they all die. So do we.
• And then remember the Dick-and-Jane books and the first word you learned - the biggest word of all - LOOK.

The Joint Commission describes some of the bad outcomes that occurs in hospitals as Sentinel Events.

Sentinel events most frequently reported* to the Joint Commission. Wrong-site surgery: 867 reports (13.5%), suicide: 770 reports (12%), op/post-op complications: 710 reports (11%), delay in treatment: 536 reports (8.3%), medication error: 526 reports (8.2%), patient fall: 406 reports (6.3%). (*6428 total reports as of September 30, 2009)

CMS list of nonreimbursable hospital-acquired conditions

1. Object inadvertently left in after surgery

2. Air embolism

3. Incompatible blood transfusion

4. Catheter-associated urinary tract infection

5. Decubitus ulcer

6. Vascular catheter-associated infection

7. Mediastinitis after coronary artery bypass graft

8. Certain types of falls and trauma

9. Surgical site infections after bariatric and certain orthopaedic procedures

10. Legionnaire’s disease

11. Manifestations of poor glycemic control

12. Iatrogenic pneumothorax

13. Delirium

14. Ventilator-associated pneumonia

15. Deep venous thrombosis/pulmonary embolism

16. Staphylococcus aureus septicemia

17. Clostridium difficile infection

When you look over these lists and think about how these things can be caused in hospitals, a lot of times you have to consider the basics that we have all been taught.  Be careful, don't work too fast, check twice, keep things clean, don't let people fall...

Wednesday, July 11, 2012

What People Don't Want - Fairness!

Be Fair Anyway

I try to be fair.  That is such a hard management skill.  People are always jockeying for position.  Everyone comes to the leader with an agenda.  As leaders we want to be liked and popular, but that remains elusive if we are committed to fairness.  When an employee steps out of line and they have been critical of our leadership we want to be arbitrary and capricious, but dang, if we are to be fair, we have to treat them the same way we did our golf buddy employee who did the exact same thing last week.  That's hard.  Our employees don't want to be treated fairly.  It's not just our employees, none of us want to be treated fairly.  I can prove it.....

You are driving home today and you are pulled over by the Highway Patrol for speeding.  What do you want the officer to do?  You want him to give you a warning and let you go.  But, you want him to give a $100 ticket to every other speeder on the road who is endangering your life!  That's not fair.

We all want to be treated differently to our advantage.

The sooner you realize that point, you will realize why you can never make all of your team members or employees happy.  If you treat them unfairly, they are not happy, because other people are getting special treatment.  If you treat them fairly, they are not happy, because they are not getting special treatment.

The only ethical way, as a leader that I can deal with this in my own mind is to treat everyone fairly.  My job is not to treat people the way they want to be treated, but to treat them the way I would want to be treated.  For me, I have decided that I would prefer to be treated fairly.

Figuring Out Fair Website

So, let me explore some fairness situations:

PRECEDENT:  Precedent is when an act, case, or decision serves as a guide or justification for subsequent situations.  As a general rule, when you decide to handle something in a particular way, to be fair, you would handle similar situations in the same way.  To handle something differently could be construed as arbitrary (subject to individual will) or capricious (unreasonable). 

      Example:  an employee is late for work.  You pull the employee into your office and have a documented discussion about the impact on workflow and the impact on other employees.  You advise that according to policies that 3 tardies constitutes an unexcused absence.

The next day another employee is late for work, but you know that this employee had been having car problems so you ignore the tardiness.

Fair or Unfair?

The above example is over simplified.  Most employment issues are much more convoluted.  But starting there, you can see how employees can see unfairness being applied in their workplace and begin to build resentment against the leader.

WHEN IT ALL GOES BAD:  It is interesting to me that when I hear grievances from employees, how often I hear the equivalent of "It was all fun and games, until someone got hurt".  Essentially, managers who fail to hold people equally accountable frequently end up with an unhappy employee grieving their disciplinary action to a higher authority claiming unfair treatment.  "X employee did the same thing I did and they didn't get in trouble."  It takes an incredible amount of time to chase all those rabbits down and figure out whether or not there is unequal treatment being applied in the workplace.  Managers have to remember that what is permitted is promoted.

When I teach a course on management principles I use a lot of case studies.  When you look at a case on accusations of sexual harassment or hostile work environment, the ones that are not bona fide cases of poor management can be traced back at times to employees who were scorned because they felt treated unfairly for one reason or another.

Leadership is not a popularity contest.  You have to have an internal guide to assist you determining the best course of action.  Fairness is a great tool to have at your disposal.

5 Ways to Shape Ethical Decisions

Thursday, July 5, 2012

Make a Difference Every Day

Sometimes the job is just too large to make a difference.  For as long as I can remember, I have had more employees than I can visit in a day.  There are more people that need help than we can help in a day.  There is more work than we can do in a day.  When I feel overwhelmed, I remember the story of the little boy who was seen throwing starfish back into the ocean.  When chided on the futility of his labor, he picked up a starfish, threw it in the water, and said "I made a difference for that one!"

Sometimes, instead of having the mind of a child, we overthink things and let the task at hand overpower us.  All we can do is one step at a time no matter what we have to accomplish.  Sometimes we can see the wisdom in making that step a LEVERAGED TASK.  I have written earlier about delegation.   True leaders can get more done through delegation than by doing everything by themselves.  If you have a critical message to relay, it would be better for you to relay it by video or to three people who can pass it on to other shifts than for you to run yourself ragged trying to see 400 staff members. 

It is just as important to be satisfied with those direct impacts that you do have time to make.  No, you can't be everything to everybody.  But when you have 5 minutes to spend with someone, you can make that 5 minutes count.  It can be an opportunity to limit distractions and focus on that other person.  An opportunity to praise and to reset expectations.  In doing so you are performing another LEVERAGED TASK.  This person, with whom you work will be able to be more effective than you would be.  Those 5 minute talks brings role clarity to them and helps them to do as you would do, if you could.  It also helps to recharge their batteries.  High performers don't need much more than these short encounters for them to know that they are on the right track.  They are mostly independent as long as they know that you are pleased with their direction.  You can feel good as you walk away from the conversation and say "I made a difference for that one!"

Sunday, July 1, 2012

Every Customer, Every Time

One of the best experiences I have had of being coached by another was when my organization hired Quint Studer's organization to infuse his principles into our company.  I was assigned Julie Kennedy, an experienced ED Nurse and Studer coach to teach me the "Must Haves".  As I applied the principles, our patient satisfaction scores soared to the top.  One of the main principles was "Every Customer, Every Time".  Our staff had to learn to provide a consistent customer service approach to every single customer.  If variability is the enemy of quality, then a quality experience for a customer means that every contact with an organization must be a positive one.  Just one bad experience can turn an "Excellent" rating to a "Good" rating.

So what if you are having a bad day when you are called upon to interact with a customer?  Doesn't matter, it's not about you...it's about the customer.  If you are really committed to customer service then you will be "on stage" for customer (as Disney would say it) no matter what is going on in your life.  At a basic level, you are  being paid to provide excellent customer service, and your boss has not given you permission to represent him/her or the company poorly.

In any case, the customer deserves the best from each component part of our company because they have sought services from the company and certainly did not seek for those services to be mediocre, rude, or poor.  We have all been victimized by poor customer service and we did not appreciate it.  In healthcare, an added dimension is that WE DON'T KNOW WHERE OUR CUSTOMERS ARE RIGHT NOW.  What I mean by that is that some of our customers have taken a moment to come down to the cafeteria and encounter you serving them while their parent lies languishing in the ICU.  Their mind is still in the ICU.  That customer deserves your very best.  Perhaps your role is to give directions to people on the hospital campus when you encounter a panicked couple running toward you.  They need directions to the ER where their son has been taken after a car wreck.  They deserve your compassion.  No matter what your role is, you will encounter customers at their very best and at their very worst.  These times will result in "moments of truth" when you can show what you are made of!  Treat others the way you would want to be treated, every customer, every time.