Imagine you are a student watching a cardiac surgical case that went very smoothly with the exception of a few random episodes of sudden drop in the blood pressure. Each time those ‘episodes’ resolved by the anesthesiologist manipulating the arterial catheter, suggesting that it was a false pressure reading. The surgeon just left the room to make a phone call and another episode happens. This time, the blood pressure reading – 50/20 – did not get better after flushing the arterial line. The circulating nurse notices other parameters are abnormal that weren’t before and calls this out. The anesthesiologist now understands the low pressure is real. Two things then happen simultaneously: the perfusionist calls the surgeon and anesthesiologist gives epinephrine. The OR tech, who still has on sterile attire, gets all the instruments ready to reopen the chest. The surgeon arrives quickly and after opening the chest, notices blood clots pressing on the heart causing the low pressure. A small bleeding point is sutured and the chest is reclosed. The patient has an otherwise uneventful recovery.
Episodes like this happen very frequently in a dangerous field like cardiac surgery. What distinguishes a high performing team is their expert use of teamwork to resolve things quickly. Team members are free to speak up honestly and openly and others listen and act. This is a powerful combination that yields a treasure trove of information. It enables teams to dig deeper than others in detecting problems before they cause harm using a proactive strategy called feedforward. This is different than basic feedback model used by most teams in the OR and throughout the hospital. The standard, status quo approach is to develop corrective action based on feedback about what caused an adverse event. The outcome this approach strives for is far from high performance. It reacts to evidence of malpractice – a hospital infection that should have been prevented, an operation on the wrong patient or the death of a patient that was very low risk. It looks for compliance with mandatory processes like handwashing, checklists, and adequate staffing with ICU specialists.
Monitoring for malpractice is a start, but it does not measure whether teams are performing at a high level. We are acting like the person who realizes he has lost his keys after spending a few too many hours at the bar. Looking up and down the dark street, he decides to focus his search under the single lamppost. His friends ask why he is just looking in this one place. He replies: “It’s where the light is.” Great teamwork might happen from time to time, but scaling it up at a hospital level won’t happen by choosing metrics just because they are near the lamppost. If we don’t get our measurements right, we don’t improve.
We want to measure how well our teams apply feedforward in order to improve the reactive mindset. Here’s an example of how I do that in my practice. During a heart operation, I often give a cold, high potassium solution into the heart so that it stops beating and is protected from harm. Using standard techniques, the solution goes into the coronary circulation and then into the heart muscle as long as the aortic valve closes normally while it is given. If the aortic valve does not close normally, the solution does not go in properly and the heart is inadequately protected. This causes the patient’s heart to suffer during the surgery and I would be blamed for using a poor technique. While this is all happening, others in the OR – the anesthesiologist and the perfusionist – have tools to monitor aortic valve closure. When they see a problem, I explicitly request them to advise me when another, non-standard technique for heart protection would be better. It is my primary responsibility to make sure the proper technique is used. But I don’t just wait for a problem and then react. Instead, I build in redundancy of teamwork to protect the patient if I miss something. The culture in most cardiac ORs is that no one ever dares to suggest to a surgeon how to do surgery, just like they tolerate surgeons that don’t participate in the time out OR checklist. HRO look for opportunities to use redundancy to minimize risk and use debriefing to identify these opportunities. They feedforward these ideas to correct any deviance until their processes work every time.
High performing teams thrive within a highly reliable organization (HRO). These are organizations with systems and processes that enable consistently low harm despite having to work under hazardous conditions. Patients and surgical teams would benefit greatly if hospitals were on the list of HRO. Unfortunately, none currently meet its basic tenets. A wide array of healthcare agencies, such as the Joint Commission, Leapfrog Group, the Institute for Safe Medication Practices, the National Quality Forum, the National Patient Safety Foundation, CMS, IHI, and AHRQ, are all calling for hospitals to dedicate themselves to high reliability. There is a growing cottage industry of advisors on how that transformation should happen.
HRO use feedforward because their teams have the freedom to speak up. This requires a level of trust that doesn’t currently exist between clinicians and hospitals. The fundamental hurdle is a culture in modern hospitals that often borders on being called “toxic”. Here is proof of the problem. A 2018 survey of physicians in the US that showed that the majority have an adversarial relationship with hospital administration and 65% feel they have little influence on how hospitals are run. Also, an AHRQ culture of safety survey has repeatedly shown over the past decade that the vast majority of nurses feel that hospitals have a punitive response to error and a tendency to blame the person involved. Bad culture permeates even the most prestigious hospitals. Johns Hopkins – a top 5 hospital ever since US News started publishing its rankings – performed an internal investigation and found “fear at every level” due to bullying. The investigation ended up disciplining 55 physicians and removing 9 from positions of power. Even patients perceive what is going on – a survey showed that 50% feel that hospitals do not provide compassionate care.
To understand what happens to teamwork in a toxic organization, let’s reconsider the opening case right after the OR nurse calls out the problem with the blood pressure. This time, the anesthesiologist is too focused on the arterial line to hear the nurse. The perfusionist assumes the anesthesiologist doesn’t agree with the nurse’s interpretation so he doesn’t call the surgeon. This delays surgeon’s arrival several minutes before the chest is opened so now the fibrillating heart does not recover. The death is investigated and records only a technical error of bleeding. The circulating nurse feels it was a preventable death due to a teamwork error so she speaks up and suggests that some of the blame is on the anesthesiologist. This comment is not accepted warmly by hospital administration who only get the physician’s side of the story. In the name of “teamwork”, the nurse is asked to resign from the cardiac team. Those that remain have learned their lesson.
Many of the published HRO initiatives start with the idea that culture change is needed but then show surprisingly little ambition on creating any real change. An inconvenient truth for most CEOs is that the majority of their employees and customers don’t trust them. Asking to become an HRO in a toxic culture is like trying to harvest crops before tilling the soil and discovering it is covered with asphalt. A CEO who has contributed to this culture and is really ambitious about creating real change should offer to resign. At the very least, sincerely apologize and then resign later if the culture doesn’t improve. Since there is no trust, an apology would never be enough to prove that they were really sorry.
A CEO that offers to resign would get my attention, but not my trust. That builds slowly by consistently and honestly walking the talk. We can talk about admitting mistakes as the best way to learn, but walking the talk is when the CEO is honest and candid about his/her own mistakes. Then, be humble and ask clinicians for feedback on how the executive team’s decisions could improve. It is easy to talk about deferring decisions to those on the front lines. It is much harder to walk around long-standing hierarchies that mandate all major decisions to be made by those with authority (CEO, department chairs, etc). An articulated vision for creating better culture must permeate every leadership action – ideas for new projects or investments, how investigations are handled, and who is interviewed for jobs. The closer things get to real change, the closer the staff will start watching. Its not just about creating a better culture for others, but with others so they know their decisions will be supported when a patient is in trouble.
Physicians and nurses know what George Orwell understood “no one ever seizes power with the intention of relinquishing it.” If collaboration with followers is unlikely, leaders focus on acquiring and maintaining power. It is curious that not even those most passionate about hospitals becoming an HRO have put the topic of toxic leadership on the table for discussion. If avoiding this topic was a ploy to make the idea of HROs more palatable to those in charge, the effort has failed before it started. It isn’t any more likely to work than the idea that electronic records were going to improve hospital costs by cutting out middlemen (e.g. unit clerks). How gullible are we to these impossible ideas?
So its not likely to happen, but is there any harm trying? Yes. As staff are being recruited into a futile effort like this, they are given a series of mixed messages that amount to what psychologists call a double bind. This has three basic components – damned if you do; damned if you don’t; damned if you notice that you’re damned either way. When it comes to the topic of HRO, staff are told it is important to speak up about safety concerns, but they know the culture doesn’t really allow them to be honest. Investigations have shown that speaking up is unusual in nurses. In part, this is because those that speak up about the many systems problems are labeled as complainers while those that are quiet, develop clever workarounds and don’t complain are promoted. Staff hear administrators say “we want you to speak up” but know the unspoken message is “if you do, you will be punished and if you call me out as hypocritical, then you’re not a team player and disqualified to speak.” In the name of speaking up, staff are barred from even pointing out that the very idea of an HRO puts them in an unsolvable double bind.
The more the topic of HRO comes up, the more double bind communication happens. Over time, this takes an emotional and mental toll. In the end, staff develop learned helplessness, like the research dog that doesn’t try to escape after being shocked too many times. They might end up with depression, anxiety and burnout, making them even less likely to speak up. Those that speak up are usually those most hopeful about an HRO and the most angry its not going to happen. Being outspoken is never celebrated, but sometimes tolerated, at least until the criticisms are directed towards hospital leadership. The small fraction of comments that might provide valuable feedback to hospital leaders are quickly discounted as naïve and lacking in “organizational savvy”. (do you get a sense that I’ve heard phrase before?)
Someone more savvy than me would be able to decipher what a hospital administrator really wants when they talk about the wholesale reprioritization of patient safety of an HRO while also demanding lower costs and higher productivity at the same time. That they don’t want to spend too much time training the principles of safety science because staff might quit and take their knowledge to competitive institutions. They engage in superficial executive walk-arounds to “give staff voice”, but don’t have the time or interest to become an executive member of patient care teams as described by Peter Pronovost’s CUSP program.
I work at a hospital that is part of a large corporate chain, called CHS. Their website describes a series of tools they’ve used to “adopt a High Reliability culture”. I have talked about this with nurses and staff that work at CHS. I came away from these discussions sensing an initiative devoid of the passion that characterizes those on the front lines I’ve met from HROs outside healthcare. In addition, CHS has not been transparent with their safety results as one of only a few that refused to provide safety data to Leapfrog Group. A lack of transparency and passion leaves them with a series of well packaged ideas that end up looking like high reliability but never able to operate like one. CHS executives can dress up with a mask of a duck’s bill, put on webbed feet and stick on feathers, but that doesn’t make them a duck.
Admittedly, this is hospital HRO 1.0. We have to start somewhere. However, the fatal flaws of these initial efforts are so obvious that it seems like the idea was meant to be an illusion. It is appropriate that hospitals want to climb out of the deep hole they are in regarding patient safety but even more important that they stop digging. The unintended result of the half-hearted initiatives like that at CHS has been double bind messages that aggravate distrust and create an even deeper hole. Real culture change comes with a hefty price. That price is the need to consider how well the command and control philosophy is serving patients. An overhaul of our mental models, not just our business models, is necessary to realize a future where nurses can speak up and protect patients better. I will analyze those tough considerations in my next post.
