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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..

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