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| The wave monster is coming! |
"What can Mommy do to help you?" I asked.
She said, "Mommy, I need you to fix the world. It is so backwards."
Cue awkward, clueless silence for one moment...and then two...before I finally get it.
My Daisy is a lefty. And she's right...her world is backwards. Scissors, doorknobs, toilet paper dispensers, restaurant place settings...you name it, it is set up for the right-handed.
After a moment of irrational planning that involved tearing down and refitting the entire world to serve my daughter, I arrived at a most unpleasant solution.
This cannot be fixed.
So I bent down and said, "It was a hard day, wasn't it?" And then I let her cry. Because if she doesn't struggle and learn to fight her own battles, she'll never be the woman she was intended to be (Carr, 2016, 12 September).
I think of Daisy's left-handed difficulties often at work. The relationship-building necessary to move my quality projects forward is a constant struggle. It does not come naturally to me. My default is to get the job done and say hello later (if at all). Unfortunately, like Daisy's challenge, my organization is set up for the opposite. I too must struggle to grow and learn (Carr, 2016, 12 September).
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| (Double Quotes, 2017) |
One such struggle is permanently etched in my memory. Early in my quality career I was assigned a project focused on reversing a trend of poor outcomes. At the start, my attempt to jump in and set things right led to defensiveness on the part of the clinical teams and unchanged patient data. In hindsight, this was a huge mistake. No matter my personal preference, I must understand and tailor my approach to the rest of the team. It was not until I stepped back, listened, and allowed space for relationship that data began to improve. Though this was incredibly uncomfortable for me, I learned (the hard way) about how to get things done respectfully.
I have always admired leaders who exhibit respectful and effective management of teams. During my bedside career, one of my leaders lived her personal goal of, "Every mistake is an opportunity for learning" out loud. To this day, I watch her incredible ability to form relationships quickly while also improving care at the patient level. As I learn more about leadership, it seems that her success lies in transparency. Everyone sees her learning and growing and questioning and working through change (Porter-O'Grady & Malloch, 2015). The empowerment that stems from her example is palpable. I aspire to be this kind of motivated leader (Porter-O'Grady & Malloch, 2015).
This is in direct contrast to a previous leader, whose closed-off demeanor and unmotivated attitude seeped through the nursing unit where I practiced as a new graduate nurse. As patient acuity was increasing, this leader said things like, "We aren't going to get any more staff so we will just have to work harder and hope bad things don't happen."
Ugh. I aspire to never be this kind of unmotivated leader. We (her staff) were not ready to meet the challenge head on. We followed her lead and "did the best we could." It was difficult to be creative or try new ways to manage our complicated patients. We needed a leader to help us rise to the occasion, but all we got was a fellow grumbler (Porter-O'Grady & Malloch, 2015).
This is in direct contrast to a previous leader, whose closed-off demeanor and unmotivated attitude seeped through the nursing unit where I practiced as a new graduate nurse. As patient acuity was increasing, this leader said things like, "We aren't going to get any more staff so we will just have to work harder and hope bad things don't happen."
Ugh. I aspire to never be this kind of unmotivated leader. We (her staff) were not ready to meet the challenge head on. We followed her lead and "did the best we could." It was difficult to be creative or try new ways to manage our complicated patients. We needed a leader to help us rise to the occasion, but all we got was a fellow grumbler (Porter-O'Grady & Malloch, 2015).
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| (Quote Fancy, 2017) |
Dr. Atul Gawande, a surgeon and healthcare thought leader, discussed this need for change-ready healthcare professionals in a 2012 TED Talk (Gawande, 2012). In the talk, Dr. Gawande addressed major issues (variable quality, high cost, fragmentation) in healthcare today and advocated strongly for a new, team-based system that leverages good ideas from other high-risk industries and prizes collaboration (Gawande, 2012). In the current state, so much of the care happens in isolated siloes controlled by independent professionals without the tools or leadership to achieve patient-centered integration through the continuum. Successful overhaul of American healthcare requires a systems-based, data-driven, coordinated change effort led by motivated leaders (Porter-O'Grady & Malloch, 2015). Without this approach, Dr. Gawande's vision will remain unrealized.
An additional critical aspect of healthcare transformation is Just Culture (Dekker, 2013, 29 May). Just Culture focuses on the systems-level and views errors as learning opportunities (Dekker, 2013, 29 May). It is important to note that Just Culture organizations continue to hold staff accountable for individual behavior and willful choices (Dekker, 2013, 29 May). Most of my work is driven by systems-level thinking and process improvement, and my organization has a healthy Just Culture in place. However, in my experience there are still small pockets of staff that hesitate to report near misses or errors. I have learned that many of these staff members had been "burned" in the past by a previous leader or organization. This experience lives on through fear of retribution despite the current supportive environment. So far, the only effective intervention for this seems to be continued engagement and "living out" the Just Culture. One very public example lies in Dr. Brian Goldman's courage in admitting his mistakes via a TED Talk (Goldman, 2012, 29 January). Dr. Goldman's transparent admission must be replicated over and over to help healthcare talk about error. We cannot begin to make things right unless we know what goes wrong (Goldman, 2012, 29 January).
Mandatory reporting facilitates Just Culture to a certain degree. In Washington State, healthcare facilities are required to report all occurrences of events designated as Serious Reportable Events (SREs) by the National Quality Form (NQF) (Revised Code of Washington, 2017). Each report must contain a systems-level root cause analysis and action plan. It is not sufficient to terminate the person or persons involved in the error (Revised Code of Washington, 2017). Though disciplinary action may be appropriate, this process forces organizations to not only track important data, but also evaluate errors from a systems perspective (Porter-O'Grady & Malloch, 2015). I am very familiar with the process at my organization due to my role in quality. We use a multi-disciplinary approach led by Patient Safety Specialists to understand opportunities and implement corrective action. It is worth reiterating that the Just Culture at my organization facilitates this team-based, systems-level approach. It is possible that Mandatory Reporting in a more punitive organization may be less effective at promoting Just Culture principles.
Dr. Pat Ebright, a nursing thought leader, devoted part of her career to understanding the kind of leadership that both healthcare and nursing needs to move forward (Ebright, 2010, 2 February). Dr. Ebright's views on nurse staffing as more than just nurse bodies and patient census is becoming embedded at my organization. As a part of my quality data, I track turnover and skill mix in addition to hours per patient day, and graph these metrics with nursing indicators such as falls and pressure injuries. In addition, leaders understand the impact of acuity, churn, and nursing experience on patient care; however it is very difficult to operationalize a staffing model to address these complex factors. A few units such as critical care and step down have acuity-based models that account for nurse experience, but this has been difficult to spread to the medical surgical settings where acuity is more difficult (and less objective). Despite this challenge, the nursing leadership is very flexible, motivated, and systems-focused. Several new models are being trialed including post-residency seminars and a twelve-month mentoring program for new graduate nurses. I look forward to seeing how this leader attitude, skill set, and willingness to try a different approach further translates into innovative staffing and staff support models (Porter-O'Grady & Malloch, 2015).
In my organization, Dr. Ebright's thoughts on the blunt end/sharp end framework are well known among quality professionals (Ebright, 2010, 2 February). One leader's interpretation of this structure is very useful as I work to resolve safety issues, "Do not allow the blunt end to dictate everything the sharp end must do. Those at the sharp end know the work best, and therefore are uniquely positioned to have new, better, effective ideas." This ties in closely with how experienced nurses manage the complexity of their day via stacking, peeking, and prioritizing (Ebright, 2010, 2 February). As a member of the blunt end, I cannot predict how a practice change could affect the nurse and the patient. The first example that comes to mind is documentation. Many times a suggested change involves either altered or new nursing charting. It is critical to involve nurses in the design as only they know what "makes sense" from a practical, patient-focused perspective (Ebright, 2010, 2 February). I have learned first-hand that missing the nursing involvement step leads to less-than-effective implementation. A quality co-worker of mine with many years of experience called the negative effects of blunt end-driven interventions, "unintended consequences." Thankfully despite my place at the blunt end, my peeking skills remain intact (Ebright, 2010, 2 February)! The ability to read the hospital unit by simply walking down the hall is priceless for a quality professional. It answers questions like, "Is now a good time to talk to staff about improvement work?" Many times giving a busy, high-acuity unit an hour or two to "settle" makes conversation and staff engagement easier. My goal is to avoid being "just another interruption" in a long shift. Just as I live out change and transparency, I must also model ways to facilitate a healthy patient care environment (Porter-O'Grady & Malloch, 2015). Showing staff that I respect workflow by minimizing non-urgent interruptions is simple, and reinforces similar behavior modeled by nursing leaders. As my patient relations colleague says, "We are always on stage, so make your work shine."
Lastly, the move towards value-based purchasing is positive, and may partially facilitate a better system for our patients (Porter-O'Grady & Malloch, 2015). However, as I have learned in my personal work, it is incredibly hard to measure value (or anything else in healthcare). Do the outcomes we are measuring actually mean something? For example, overall hospital mortality is considered a "big dot" metric, and decreasing mortality is generally seen as an indicator of value. However, for patients with terminal illness, is the value really based in prolonging life (and improving mortality)? Or is it better to have timely end-of-life discussions that focus on quality, comfort, dignity, and patient choice (potentially increasing the mortality rate)? I do not know the answers, but at a basic level I am glad we are at least making an effort. As a quality professional who is deeply passionate about measuring, I look forward to being included in the discussion.
The best thing about nursing is the opportunity to grow and learn with patients and colleagues. As a more experienced nurse in a position of informal leadership, it is my responsibility to show others Just Culture, change readiness, and transparency through everyday actions. The expectations are high, but so are the rewards.
An additional critical aspect of healthcare transformation is Just Culture (Dekker, 2013, 29 May). Just Culture focuses on the systems-level and views errors as learning opportunities (Dekker, 2013, 29 May). It is important to note that Just Culture organizations continue to hold staff accountable for individual behavior and willful choices (Dekker, 2013, 29 May). Most of my work is driven by systems-level thinking and process improvement, and my organization has a healthy Just Culture in place. However, in my experience there are still small pockets of staff that hesitate to report near misses or errors. I have learned that many of these staff members had been "burned" in the past by a previous leader or organization. This experience lives on through fear of retribution despite the current supportive environment. So far, the only effective intervention for this seems to be continued engagement and "living out" the Just Culture. One very public example lies in Dr. Brian Goldman's courage in admitting his mistakes via a TED Talk (Goldman, 2012, 29 January). Dr. Goldman's transparent admission must be replicated over and over to help healthcare talk about error. We cannot begin to make things right unless we know what goes wrong (Goldman, 2012, 29 January).
 |
| (Freeduh, 2011) |
Mandatory reporting facilitates Just Culture to a certain degree. In Washington State, healthcare facilities are required to report all occurrences of events designated as Serious Reportable Events (SREs) by the National Quality Form (NQF) (Revised Code of Washington, 2017). Each report must contain a systems-level root cause analysis and action plan. It is not sufficient to terminate the person or persons involved in the error (Revised Code of Washington, 2017). Though disciplinary action may be appropriate, this process forces organizations to not only track important data, but also evaluate errors from a systems perspective (Porter-O'Grady & Malloch, 2015). I am very familiar with the process at my organization due to my role in quality. We use a multi-disciplinary approach led by Patient Safety Specialists to understand opportunities and implement corrective action. It is worth reiterating that the Just Culture at my organization facilitates this team-based, systems-level approach. It is possible that Mandatory Reporting in a more punitive organization may be less effective at promoting Just Culture principles.
Dr. Pat Ebright, a nursing thought leader, devoted part of her career to understanding the kind of leadership that both healthcare and nursing needs to move forward (Ebright, 2010, 2 February). Dr. Ebright's views on nurse staffing as more than just nurse bodies and patient census is becoming embedded at my organization. As a part of my quality data, I track turnover and skill mix in addition to hours per patient day, and graph these metrics with nursing indicators such as falls and pressure injuries. In addition, leaders understand the impact of acuity, churn, and nursing experience on patient care; however it is very difficult to operationalize a staffing model to address these complex factors. A few units such as critical care and step down have acuity-based models that account for nurse experience, but this has been difficult to spread to the medical surgical settings where acuity is more difficult (and less objective). Despite this challenge, the nursing leadership is very flexible, motivated, and systems-focused. Several new models are being trialed including post-residency seminars and a twelve-month mentoring program for new graduate nurses. I look forward to seeing how this leader attitude, skill set, and willingness to try a different approach further translates into innovative staffing and staff support models (Porter-O'Grady & Malloch, 2015).
 |
| (Only a Nurse, 2017) |
In my organization, Dr. Ebright's thoughts on the blunt end/sharp end framework are well known among quality professionals (Ebright, 2010, 2 February). One leader's interpretation of this structure is very useful as I work to resolve safety issues, "Do not allow the blunt end to dictate everything the sharp end must do. Those at the sharp end know the work best, and therefore are uniquely positioned to have new, better, effective ideas." This ties in closely with how experienced nurses manage the complexity of their day via stacking, peeking, and prioritizing (Ebright, 2010, 2 February). As a member of the blunt end, I cannot predict how a practice change could affect the nurse and the patient. The first example that comes to mind is documentation. Many times a suggested change involves either altered or new nursing charting. It is critical to involve nurses in the design as only they know what "makes sense" from a practical, patient-focused perspective (Ebright, 2010, 2 February). I have learned first-hand that missing the nursing involvement step leads to less-than-effective implementation. A quality co-worker of mine with many years of experience called the negative effects of blunt end-driven interventions, "unintended consequences." Thankfully despite my place at the blunt end, my peeking skills remain intact (Ebright, 2010, 2 February)! The ability to read the hospital unit by simply walking down the hall is priceless for a quality professional. It answers questions like, "Is now a good time to talk to staff about improvement work?" Many times giving a busy, high-acuity unit an hour or two to "settle" makes conversation and staff engagement easier. My goal is to avoid being "just another interruption" in a long shift. Just as I live out change and transparency, I must also model ways to facilitate a healthy patient care environment (Porter-O'Grady & Malloch, 2015). Showing staff that I respect workflow by minimizing non-urgent interruptions is simple, and reinforces similar behavior modeled by nursing leaders. As my patient relations colleague says, "We are always on stage, so make your work shine."
Lastly, the move towards value-based purchasing is positive, and may partially facilitate a better system for our patients (Porter-O'Grady & Malloch, 2015). However, as I have learned in my personal work, it is incredibly hard to measure value (or anything else in healthcare). Do the outcomes we are measuring actually mean something? For example, overall hospital mortality is considered a "big dot" metric, and decreasing mortality is generally seen as an indicator of value. However, for patients with terminal illness, is the value really based in prolonging life (and improving mortality)? Or is it better to have timely end-of-life discussions that focus on quality, comfort, dignity, and patient choice (potentially increasing the mortality rate)? I do not know the answers, but at a basic level I am glad we are at least making an effort. As a quality professional who is deeply passionate about measuring, I look forward to being included in the discussion.
The best thing about nursing is the opportunity to grow and learn with patients and colleagues. As a more experienced nurse in a position of informal leadership, it is my responsibility to show others Just Culture, change readiness, and transparency through everyday actions. The expectations are high, but so are the rewards.
 |
| (Body Mind Success, 2017) |
References
Body Mind Success (2017). Walk the talk. Retrieved from http://bodymindsuccess.com/do-you-walk-the-talk
Carr, J.L. (2016, 12 September). A secret to parenting that no one tells you: The strength is in the struggle [Blog post]. Retrieved from http://annvoskamp.com/2016/09/a-secret-to-parenting-that-no-one-tells-you-the-strength-is-in-the-struggle/
Dekker, S. [Erik Sibla]. (2013, 29 May). Sidney Dekker: Just culture (Full lecture). [Video file]. Retrieved from https://www.youtube.com/watch?v=gKqYMpWZbV8
Double Quotes (2017). C.S. Lewis quotes. Retrieved from http://www.doublequotes.net/quotes/c-s-lewis-quotes-experience-that-most-brutal-of-teachers-but-you-learn-my-god-do-you-learn
Ebright, P. [mentorsgallery]. (2010, 2 February). Pat Ebright: Blunt end versus sharp end. [Video file]. Retrieved from https://www.youtube.com/watch?v=Dv1BP9BGPWg
Carr, J.L. (2016, 12 September). A secret to parenting that no one tells you: The strength is in the struggle [Blog post]. Retrieved from http://annvoskamp.com/2016/09/a-secret-to-parenting-that-no-one-tells-you-the-strength-is-in-the-struggle/
Dekker, S. [Erik Sibla]. (2013, 29 May). Sidney Dekker: Just culture (Full lecture). [Video file]. Retrieved from https://www.youtube.com/watch?v=gKqYMpWZbV8
Double Quotes (2017). C.S. Lewis quotes. Retrieved from http://www.doublequotes.net/quotes/c-s-lewis-quotes-experience-that-most-brutal-of-teachers-but-you-learn-my-god-do-you-learn
Ebright, P. [mentorsgallery]. (2010, 2 February). Pat Ebright: Blunt end versus sharp end. [Video file]. Retrieved from https://www.youtube.com/watch?v=Dv1BP9BGPWg
Ebright, P. [mentorsgallery]. (2010, 2 February). Pat Ebright: Stacking. [Video file]. https://www.youtube.com/watch?v=IVHbty3iI9k
Ebright, P. [mentorsgallery]. (2010, 2 February). Pat Ebright: Complex adaptive systems theory. [Video file]. Retrieved from https://www.youtube.com/watch?v=VNFFEJqz9YA
Freeduh (2011). Our company's new transparency policy. Retrieved from http://www.freeduh.com/2011/10/20/our-companys-new-transparency-policy/
Gawande, A. [TED2012]. (2012). Atul Gawande: How do we heal medicine? [Video file]. Retrieved from https://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine
Gawande, A. [TED2012]. (2012). Atul Gawande: How do we heal medicine? [Video file]. Retrieved from https://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine
Goldman, B. [TED Talks]. (2012, 15 January). Doctors make mistakes: Can we talk about that? [Video file]. Retrieved from https://www.youtube.com/watch?v=gKqYMpWZbV8
Only a Nurse (2017). Humor. Retrieved from http://www.onlyanurse.com/humor-1/kindalikeadoctor
Porter-O’Grady, T. & Malloch, K. (2015). Quantum Leadership: Building better partnerships for sustainable health (4th ed.). Sudbury, MA: Jones & Bartlett.
Quote Fancy (2017). Five wallpapers. Retrieved from https://quotefancy.com/quote/33296/Antoine-de-Saint-Exup-ry-If-you-want-to-build-a-ship-don-t-drum-up-the-men-to-gather-wood
Revised Code of Washington (2017). Revised Code of Washington 70.56.020. Retrieved from http://app.leg.wa.gov/RCW/default.aspx?cite=70.56.020
Only a Nurse (2017). Humor. Retrieved from http://www.onlyanurse.com/humor-1/kindalikeadoctor
Porter-O’Grady, T. & Malloch, K. (2015). Quantum Leadership: Building better partnerships for sustainable health (4th ed.). Sudbury, MA: Jones & Bartlett.
Quote Fancy (2017). Five wallpapers. Retrieved from https://quotefancy.com/quote/33296/Antoine-de-Saint-Exup-ry-If-you-want-to-build-a-ship-don-t-drum-up-the-men-to-gather-wood
Revised Code of Washington (2017). Revised Code of Washington 70.56.020. Retrieved from http://app.leg.wa.gov/RCW/default.aspx?cite=70.56.020
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