Errors as Opportunities

Learning from mistakes

As a nurse for many years, I have learned it is best to take the extra time to check and double check things. I have seen many errors over the years, because I, or someone else, was in a rush, and a pause to clarify or check details was omitted. It is easy to assume the intent of an order is understood, even if it seems odd or incorrect. It is easy to miss a discrepancy in dosing, because time is not taken to look it up. Our organization has a “high reliability” campaign in place, and every employee is required to attend error prevention training. The tools learned there are becoming part of the regular vocabulary in emails, presentations and even face-to-face discussions: team member checking, clarifying questions, ARCC, STAR and several others. These tools go hand in hand with the leadership style of the Information age, because they create horizontal relationships and encourage everyone to ask questions, make suggestions, and voice safety concerns, regardless of their “rank” in the organization. It does not happen overnight, but changes are apparent!

Responding to conflict and errors

Our medical director is a leader who handles conflicts and errors well. He is slow to judge, gathers information, and likes to take the “30,000 foot view” when considering situations. He is not reactive, but instead he gives thoughtful consideration and asks for input from others before making decisions. When a reportable event occurred a while ago, his response was to talk with those involved, review the chart, and maintain a calm demeanor. He also demonstrated great concern for the staff involved and their well-being, speaking to all in a supportive manner and avoiding blame. This approach is a stark contrast to another leader I worked with in my early years as a nurse. This leader’s approach was more hierarchical and controlling. Her tone was condescending, and she had a negative attitude towards the staff. She was more likely to place blame on people, thus, most nurses were not forthcoming when an error was made. Ultimately, the situation put patient safety at risk, because potential system problems could not be identified and remedied when people were afraid to report errors.

As a CN, I strive to connect with everyone I work with. Sometimes I worry about the time used chatting with nurses, especially if it is non-work related, but it is ultimately time well spent. I know people more personally and have a sense of who they are. I find a nurse is more likely to hear me and trust what I have to say, when they know me. I can relay safety information as a helpful tip or something nurses needs to know rather than an edict they must follow, and they are not only receptive, but they perceive the interaction as supportive and helpful rather than commanding. I am always open to suggestions or ideas for improving safety, and I try to share them with others as well.

Insights from Atul Gawande

Many of the ideas Gawande discussed in his TEDx talk go right along with the high reliability work my organization is doing. Standardizing certain elements of care to ensure all critical steps are completed, taking time to think about the task at hand, and respecting the role and value of each team member’s contribution are examples of such work. I appreciated the idea of a “pause” before proceeding. In a time when technology has increased the pace of work and distractions are plentiful, taking a few moments to focus on the task at hand is essential. Providing safe care is critical to improving the quality of care, and ultimately increases the value as well.

As a non-profit organization, cost effective care is important, although perhaps for different reasons than a for-profit organization might give. In order to stay in business and offer care to all, regardless of ability to pay, the institution must closely manage the budget. The difficulty is determining what will result in cost effective care. For example, it might be more expensive to use a particular dressing on a central line, but if it does a better job of protecting the site and preventing a costly blood stream infection, the money is well spent. For these reasons, patient outcomes should also be measured, and strategies used to improve unacceptable rates. Ultimately, this approach can result in decreased costs as well as improved patient care.

Patient satisfaction should also be measured. While it can seem superfluous at times, how the patient feels about the care received holds a great deal of influence and cannot be dismissed. “Patient satisfaction affects clinical outcomes, patient retention, and medical malpractice claims. It affects the timely, efficient, and patient-centered delivery of quality health care. Patient satisfaction is thus a proxy but a very effective indicator to measure the success of doctors and hospitals (Prakash, 2010, p. 151).

Porter-O’Grady and Malloch (2015) discuss the need to eliminate things that do not contribute to good outcomes. As a QI coordinator, I wholeheartedly ascribe to the idea of efficiency and making the workload lighter in order to focus on the essentials. If a service or task is not adding value to the care of the patient, it deserves closer scrutiny and possible elimination. The value a service or task adds to the patient experience and outcome is worth measuring in order to decide which things stay and what is eliminated.

Addressing Interruptions

As technology continues to advance, there are more ways than ever to find ourselves distracted. Social media, cell phones, and email are always present and demanding our attention, but as a nurse, there is a multitude of additional interruptions to our focus. Alarms, patient needs, coworkers with questions, and new orders are a few, and the list goes on indefinitely. This problem is particularly worrisome, because a study cited by the Patient Safety Network suggests there is a 12.7% increase in the risk for a medication error with each interruption while the med is being prepared and administered.

There are many ways to tackle the issue of interruptions, and multiple aspects of care to consider. Our organization has begun looking at the issue of alarm fatigue, and changes are occurring in the default settings of our monitors. In our unit, a project is being considered to determine whether the noise level is an issue. As a CN, I find it difficult to get through lunch without multiple phone calls, and the number of interruptions as I gather report information at the end of the shift continues to grow. I try to model not interrupting if I arrive at a patient room for report and see the nurse in the midst of a complex tubing change. I move on to the next room and return to that nurse later. I have also coached nurses how to address families who are talkative, or have many requests, in order to decrease interruptions. For example, “I need to get these medications ready and give them to Billy, so I will talk with you more when I am done” or “I need to check on my other patient, so I will be out of the room for a while. I will be back at 2:00, and we can give Sarah her bath then.” As a QI coordinator, this topic would be a good one to address, as the problem is huge, and the impact directly affects patient outcomes. This idea is definitely something I need to consider.

Handling Mistakes in a Just Culture 

As a nurse in the workforce for over 30 years, I know all too well how easy it is to make an error. I also know the guilt and stress produced by errors. Rarely do errors occur due to maliciousness or neglect, but rather they usually seem to be the result of a memory lapse, inattention, misunderstanding or some other understandable, yet unfortunate, situation. I try to have a very supportive response when an error is made, because I know most nurses are devastated when something happens.

I am thankful the organization for which I work believes strongly in a just culture. There is concern for the patient, determination to investigate and avoid similar events in the future, and support for the person who made the error. Of course there may be consequences if risky or negligent behavior is involved, but overall, there is not a rush to judgement or blame, and the entire situation is approached as a system issue as the analysis begins.

The state of Missouri has recommendations related to patient safety; however, there is no requirement for mandatory reporting. As a high reliability organization, all employees are encouraged to report safety issues of any type through an internal reporting system, including “near miss” events in which no harm reached the patient. Positive feedback is given for such reporting including “great catch” awards, which are reported in the employee newsletter. While the increase in reporting requires an increase in follow-up activity, the outcome is such that problems are identified and addressed. This focus on safety and preventing errors is definitely a step in the right direction.

References

Beyea, S. (2014). Interruptions and distractions in health care: Improved safety with mindfulness. Retrieved from https://psnet.ahrq.gov/perspectives/perspective/152/interruptions-and-distractions-in-health-care-improved-safety-with-mindfulness

Boynton, B. (Director). (2012). Interruption awareness: A nursing minute for patient safety[Video file]. Retrieved from https://www.youtube.com/watch?v=PGK9_CkhRNw&t=311s

Extension Healthcare. (2016). Clinical Interruptions. Retrieved from http://www.extensionhealthcare.com/industry-challenges/alarm-management/clinical-interruptions/

MISSOURI –Public and Private PolicyMedical Errors and Patient Safety. (n.d.). Retrieved from http://qups.org/med_errors.php?c=individual_state&s=26&t=all

Porter-O'Grady, T., & Malloch, K. (2015). Quantum leadership: Building better partnerships for sustainable health (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Prakash, B. (2010). Patient satisfaction. Journal of Cutaneous and Aesthetic Surgery, 3(3), 151-155. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047732/

TEDx Talks (Director). (2012). Atul Gawande: How do we heal medicine? [Video file]. Retrieved from https://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine

Understanding Preferences and Personalities

PERSONALITIES

After taking the test on the 16 Personalities website, results indicate my personality type is INTJ. Some of the traits of this particular personality include calm, rational, reserved, and independent. It is interesting to note these descriptors are similar to those I mentioned last week when discussing how others describe me. While I think the overall description is accurate, I know I work to overcome some of the tendencies, because the situation at hand requires it. For example, it is more my style to address the issue at hand than it is to deal with the emotions of the situation. My coworkers and family can vouch for the fact that I do not have a lot of time for tears and drama, but instead I prefer to fix the problem. Working in an ICU can require that kind of objectivity at times. There are other times, however, when a sympathetic ear and a compassionate touch are needed, and I try not to ignore those situations, even though I am much less comfortable dealing with them.

Another mom and I were co-leaders of a Girl Scout troop for several years, and we were as different as two moms could be. I looked up the opposite of INTJ, which would be ESFP, and it described her quite well! She was very social, creative, nurturing, and supportive, and she had all kinds of fun ideas for our group of girls. She did not always appreciate my organized nature or request for more specific details. During one memorable discussion, she asked me in a perturbed tone, “Do you always have to be so practical?” I suppose laughing was not the supportive response…

In the big scheme of things, however, I think the two of us working together as leaders was a good situation for the troop. My ideas were not nearly as creative as hers were, yet she did not have the organizational skills to follow through with her plans. Instead, my co-leader came up with excellent suggestions, and I planned a way to make them happen. While we sometimes would be annoyed with each other, we both appreciated that the other helped fill in the areas in which we were lacking. Together we were a great team!

INTROVERTS and EXTROVERTS

Susan Cain’s TED talk about introverts and extroverts describes the differences between the two groups and suggests the world needs both. As a life-long introvert, I can identify with the need for alone time to regroup and recharge my energy. I think both personality types have much to offer, and the challenge for me is to help direct the energy of the extroverted team members or attend to the introverts need for solitude in a constructive manner.

As a CN, I will sometimes task an extrovert with a project or something that can channel their initiative, such as taking a new piece of equipment around the unit and making sure everyone is familiar with how it works. As a QI director, I try to match skills and personalities to the needs of the projects we are working on. Extroverts can be a great help when it comes to generating buy-in from the rest of the staff. On the other hand, introverts are easier for me to work with, because I can relate to them.  I know the quiet nurse or CA may have an untapped well of capabilities, and I am definitely going to tap into it to help them grow and to benefit our unit simultaneously.

I am more likely to suggest a QI project that allows a nurse to choose her level of participation, meaning she can do as much or as little as she desires. For example, she might agree to join a committee and attend a few meetings, then gradually begin to offer ideas or take on some of the work that needs to be completed. This approach is less threatening, and often people begin to contribute more as time goes on and they feel more comfortable. On the other hand, a more extroverted person might offer to be the project lead!  I think of extrovert or introvert as a guide to help me determine some of the abilities of the person and perhaps a way to fine-tune my approach to working with them. Both personalities have needed qualities!

CONFLICT RESOLUTION

Differences in personality can affect every aspect of life including the manner in which we deal with conflict. Some people may avoid it at all costs, while others seemingly create it wherever they go. Conflict can create negative emotions, and people handle it differently.  While one person may sulk or even leave the room, another may have outbursts or speak negatively with others about the situation. As a common element in most relationships, however, it is important to find healthy and productive means of dealing with conflict. As an INTJ, conflict is particularly uncomfortable, because it means I must engage with people who are exuding all kinds of energy, and it is exhausting!  On the other hand, if I have a planned response to potential clashes and controversies, my INTJ personality is better able to handle it.

Jeff Muir defines conflict as the expression of an unmet need, and he lists three steps for dealing with it:
1. Determine if the need can or cannot be met
2. If it can be met – resolve
    If it cannot be met – negotiate a resolution
3. Conflict management if unable to resolve

Dana Casperson suggests two steps to use in negotiating a conflict:
1. Don’t hear the attack
2. Develop curiosity

I agree with these recommendations, and I have seen them work. A patient advocate gave a talk to our CN group several years ago.  She said her standard way to approach an upset family is to introduce herself, pull up a chair, sit down and say, “How can I help?” In doing so, she does not “hear the attack”, because she is entering into the conversation with no preconceived ideas about the issues.  She is also is developing curiosity to truly hear what need is being unmet. I think this approach is also acceptable to many personality types because it allows for whatever kind of response the person wants to give. By offering to help, the stage is set for negotiation and resolution from the beginning. I don’t remember anything else from her talk, but that one tip has served me well many times.

INNOVATION

Jeremy Gutsche compares innovators to hunters, and he likens everyone else to farmers.  A farmer, happy with the crop from one year, will repeat the steps to obtain a similar result the next time. He describes the farmer mindset as complacent, repetitive and protective. A different approach, which has the potential to return different and better results, is that of the hunter.  A hunter is insatiable or never satisfied with the status quo.  The hunter is also curious and willing to undo the current process in order to develop a better one. While the hunter is not always successful, the constant search has a higher likelihood of discovering something completely new.

This topic really resonated with me, as I have found myself restless at times with our current projects.  While most things need ongoing measurement and oversight, it is easy to get complacent and spend the time on routine tasks. A recent conference I attended sparked some new ideas for using cell phones to streamline some processes in our unit, but implementation would require big changes to the usual organizational stance on such technology. An interesting idea to investigate!  I appreciated the task list given at the end of the talk, which included exploring curiosity, thinking about relationships in a new way, and not giving up.  I do know from experience that sometimes you have to bring up an idea multiple times with many different people before someone finally starts to really listen and think about your proposal.  This talk has inspired me to think more like a hunter!

SYSTEMS THINKING

Systems thinking is an approach to problem solving that requires looking at the entire system, as well as the manner in which the individual system components are related and have an impact on each other. This type of thinking is necessary in a large organization such as a hospital, where, too often, work is done in each department with little thought of how it affects those in other areas. When a problem occurs, it is necessary to consider the “big picture” in order to avoid solving one issue while creating other problems. Systems thinking can also help identify relationships and forces throughout the organization that may not have been known or understood prior to the investigation.

One example of a systems approach to problem solving is the Donabedian Model, which has three components: structure, process, and outcome. Examining elements of each component ensures a thorough investigation of an issue before starting the problem-solving process.  By looking at all organizational factors and relationships, it is much more likely that the necessary information is available to enable a satisfactory solution.

An example could be an ongoing problem with surgical site infections. The high infection rate is an outcome measure, but the cause of the problem, or the best type of intervention, may not be obvious. A systems thinking approach would consider what process and structural elements contributed to the outcome. Structural information gathered could include such things as the number of surgeries done each day, the number of OR rooms, the staffing, the credentials of the surgeons, the supplies and equipment used in the OR, and so on. The processes considered could include how the patient is prepped for OR, how instruments are sanitized, the manner in which OR staff prep before entering the surgical suite, and the process for administering prophylactic antibiotics.

Gathering all of this information gives the team an overall view of how the entire system fits together. Armed with the big picture, it is possible to hone in on issues that may not have been apparent during the initial discussion and consider a wider variety of interventions. It is worth noting that personalities and interpersonal conflicts can be pertinent to systems thinking, because both are elements which can define a culture and have an impact on processes.

FINAL THOUGHTS

O’Grady and Malloch discuss the evolution of our culture from the Industrial Age to the Technological or Information Age in their book, Quantum Leadership. We are in the midst of this change, as organizations are comprised of a multigenerational workforce with employees at all stages of transition. In my own institution, I work with some nurses who are completely befuddled by “cutting and pasting” in a Word document, and others who can trouble shoot a computer, cell phone, or any other piece of technology with little apparent effort. The setting is ripe for conflicts and personality clashes if not handled correctly, but some of the webcast speakers suggest these events should be embraced as a means of resolving issues and achieving growth. Furthermore, letting anger and resentment go unresolved can create team dysfunction.

The authors also suggest an effective leader will consider differences as part of their systems thinking, using their findings to develop a means of aligning the individual strengths and values of the staff with the goals of the organization. In other words, the leader should figure out the best way to present information in order to help employees understand the need for change and to gain their buy-in. Part of motivating change, however, includes allowing people to help create the change.

Those most affected by a change must be part of the change process to ensure the solutions chosen are reasonable and sustainable in the “real world”. Often those most affected are the direct caregivers such as nurses, therapists and CAs. Asking for their input when making decisions is clearly a new way of thinking for many leaders, but one which is certainly needed.

Change can be a challenge for so many reasons. Involving all stakeholders in the decision-making from the beginning offers the best chance of achieving employee investment in changes that reflect and meet organizational goals. In order to accomplish this task, an effective leader is willing to give up some of the control and allow others to be involved in problem-solving. This type of leadership is based on equity, team building, and relationships rather than a hierarchy in which the manager is in control. This type of leadership also creates accountability and ownership, both of which are of great value to the organization. While it is not easy to sit back and let others take the reins, the results can be well worth the temporary discomfort.

References

Breakthrough Marketing (Director). (2013). Conflict resolution [Video file]. Retrieved from https://www.youtube.com/watch?v=KY5TWVz5ZDU

Dawn, I. (2013). Introverts - Extroverts [Web log post]. Retrieved from https://uminntilt.com/2013/03/05/introverts-extroverts-change-takes-courage/

INTJ Personality: An Overview. (2016). Retrieved from http://www.personality-central.com/INTJ-personality.html

Porter-O'Grady, T., & Malloch, K. (2015). Quantum leadership: Building better partnerships for sustainable health. Burlington, MA: Jones & Bartlett Learning.

Shi, L., & Singh, D. A. (2015). Delivering health care in America: A systems approach (6th ed.). Burlington, MA: Jones and Bartlett Learning.

TEDx Talks (Director). (2015). Conflict is a place of possibility [Video file]. Retrieved from
https://www.youtube.com/watch?v=WfQeH3092Sc

TEDx Talks (Director). (2012). The power of introverts [Video file]. Retrieved from https://www.youtube.com/watch?v=c0KYU2j0TM4

Trendhunter (Director). (2015). Better and faster [Video file]. Retrieved from https://www.youtube.com/watch?v=VFshvhzcCVw

Why I do what I do...

SELF-REFLECTION

Some of the adjectives others have used to describe me include calm, practical, and independent. I would agree with these assessments.  A leadership survey I completed a few years ago suggested I see both the forest and the trees, and this description is accurate as well.  I would also add nurturing to the list.  While I am not necessarily a touchy-feely sort, I work hard to ensure everyone has support to achieve his or her goals. All of these attributes are useful to me as I work in my professional roles as both a charge nurse (CN) and a Quality Improvement (QI) coordinator. I derive a great deal of satisfaction from helping other nurses grow in their knowledge and skills, and watching them gain confidence in their abilities. As a mom, I have coached two children into young adulthood, and as a charge nurse and QI coordinator, I coach the nurses I work with to help them become competent professionals and possible future leaders. Of all the things I enjoy about my work, this opportunity to influence and assist my coworkers ranks the highest.

It is not characteristic of me to set long-range plans or have definite ideas of how things will go.  I am more likely to let things evolve. I did not decide to become an RN until my junior year of college, and I made a decision to obtain a graduate degree two months before my first class started. Even now, I am not sure what, if anything, will change once I have obtained my degree, but I am happy to let things take their course and see what opportunities arise. My work is challenging and engaging, and that fact is worth a great deal.

SIMON SINEK

Simon Sinek discusses the golden circle as a means of explaining why some people or institutions are able to inspire while others are not. His suggestion of knowing your mission or “why” is the most important thing, and it will give purpose to the “how” and “what”. I inserted my own answers into the circle, and it created an accurate depiction of my approach to nursing.

STEVE JOBS

Steve Jobs told about facing a major failure in his life, and how that event set him on a new course which ultimately brought about more opportunities and success than he might have achieved if the setback had not occurred. Rather than remain defeated, he took the opportunity to go in a different direction and be open to the change.

 I have experienced a similar resetting of my life course.  After working as a full-time CN for almost twenty years, I reduced my hours to a part-time position to be more available to my growing children. It was a difficult decision, but one that our family agreed was needed.  While it was hard to let go of my leadership role, it was that decision which gradually led me into the QI work that is a major component of my work today. Also, I eventually returned to a CN position, even though I only worked one day a week, because there was a need for someone to help fill in for absences and gaps in the schedule. Ultimately, taking a step into the unknown with a change in my work role led me to new and challenging work, and I was able to retain a bit of my former role as well. Most importantly, the change gave me the flexibility I needed to be available for my family, and as my children have grown and gone on to new adventures, I have a rewarding career to focus on.

MICHAEL JR

Michael Jr explains his idea that knowing the reason you do something (your “why”) will give you the motivation to give your best effort.  Without the “why”, the enthusiasm may be lacking, and the product may be of lesser quality. I can definitely apply this to my work.  Knowing my interest in developing the skills and careers of my fellow nurses, I approach both of my roles with intention.  When I make assignments as a CN, I could just go down the list of nurses and hand out patient assignments, but that is not my practice. I think about which nurses need a new opportunity, I try to challenge at least two or three of them, and I make sure they have adequate support nearby to ensure they are successful.  As a QI coordinator, I actively enlist people to help with projects, and I try to match the work to their interests and scope of practice. Rarely does anyone turn down the chance to be involved, and most people are pleased to be personally recruited.  This practice also increases engagement and ownership of the work, something that David Marquett promotes in his talk about “Greatness”.

TIM PORTER-O’GRADY

Porter-O’Grady discusses the concept of “releasing” people to do their best work.  He suggests the means for innovation rest with those directly providing care.  Nurses, physicians, therapists and others interacting with patients regularly are better equipped to identify issues.  They are also more likely to come up with sustainable solutions if they are given the freedom to work on the problem without unnecessary restraints. In the book, Quantum Leadership (2015), Porter-O’Grady and Malloch describe front-line staff as knowledge workers, because they have ownership of the work done. This situation gives direct care providers leverage, and it creates a different organizational dynamic from the familiar hierarchy model of leadership.

Another idea he proposed was the value of diversity in problem-solving and innovative solutions. The collective experiences and wisdom of a group are far greater than those of one individual.  The ideas generated will potentially be higher in number and broader in range, giving more opportunity for successful options to be presented.

A successful leader in the age of information and technology will recruit the best people, give them the freedom to improve processes or find solutions to problems, and help remove barriers to implementation. This approach makes the best use of resources, and it creates employee engagement and satisfaction.  While these ideas have not been the usual practice for nursing in the past, many nurse leaders are beginning to move in this direction. In a time of looming shortages of health care workers, a leadership method that improves processes while increasing the engagement of direct care providers is a promising idea indeed.

PERSONAL GROWTH

Nursing Administration: Scope and Standards of Practice (2016) outlines many aspects of the nurse administrator practice, and it is applicable to a multitude of nursing leadership roles.  Three areas I have identified for my own goal setting are as follows:

1) Goal – Improve verbal presentation skills.  Communication (Standard 9) – Communicates both verbally and in writing, making clear, concise, and factual presentation to a variety of audiences.

2) Goal – Increase documentation of QI projects to include completion of project workbooks.
Quality of Practice (Standard 14) – Documents practice in a manner that supports quality improvement plans and interventions.

3) Goal –  Investigate requirements for CPHQ certification, participate in study sessions offered through work. Quality of Practice (Standard 14) – Achieves professional certification, when available.

By working on these fundamental improvements, I hope to become more effective in my roles, and thus, be better able to help others become effective leaders as well.

References

AONE Nurse Leaders (Director). (2016). AONE thought leader: Tim Porter O'Grady [Video file]. Retrieved from https://www.youtube.com/watch?v=ytAV0jcIVPc

Inno-Versity (Director). (2013). Inno-Versity presents: "Greatness" by David Marquet [Video file]. Retrieved from https://www.youtube.com/watch?v=OqmdLcyES_Q

Nursing administration: Scope and standards of practice (2nd ed.). (2016). Silver Springs, MD: American Nurses Association.

Porter-O'Grady, T., & Malloch, K. (2015). Quantum leadership: Building better partnerships for sustainable health (4th ed.). Burlington, MA: Jones & Bartlett Learning.

TED (Director). (2009). Simon Sinek: How great leaders inspire action [Video file]. Retrieved from http://www.ted.com/talks/simon_sinek_how_great_leaders_inspire_action?language=en

TED (Director). (2011). Steve Jobs - TED- How to live before you die [Video file]. Retrieved from https://www.youtube.com/watch?v=lcZDWo6hiuI

Whitney, M. (Director). (2016). Michael Jr: Know your why [Video file]. Retrieved from https://www.youtube.com/watch?v=ygBUCiSDUe0