Vitality of the Medical Surgical Unit

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Vitality of the Medical Surgical Unit

• The Essential Role of Effective Team
  Communication
• Diane Miller, MBA
• Mary Viney, RN MSN
• Jane Taylor, Ed.D.
• November 2005

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Overview

• Vitality and Teamwork Within a joyful and
  supportive environment that nurtures professional
  formation and career development, effective care
  teams continually striving for excellence

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Overview of Session

• 130 -210 Overview of design targets, measures
  and measurement tool and initial survey
  results
• 210 225 Break
• 225 - 315 Engaging the team Leadership Role
  and Snorkel
• Exercise
• 315 - 340 Optimizing Team Communication
• Multidisciplinary
  Rounds
• 340 - 400 Optimizing Team Communications
  Difficult Conversations

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Vitality Target

• Top box score - Effective Team Professional
  Development Survey Questions 8 11
• This unit provides a supportive environment that
  nurtures my professional formation and
  development.
• I am part of an effective work team that
  continuously strives for excellence even when the
  conditions are less than optimal.

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How do you assess the current environment and
staff vitality on your unit?

• Team Survey
• Baseline
• Use results to diagnose your strengths
  weaknesses
• Action Plan
• Based on measures, design strategy for action
  over the next six months
• Engage staff in the design

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Survey Tool

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Category A Do I have what I need to do my job?

• Questions 1, 9 and 10
• I have the materials and equipment I need to
  accomplish my role in my unit/department.
• I have the support and communication I need from
  other staff to care for patients.
• The work environment is pleasant and comfortable
  on this unit.

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Results Q1
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Results Q9
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Results Q10
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Category B Am I empowered to contribute and
transform?

• Questions 4 and 6
• My opinions really seem to count in the
  transformation of this unit/department.
• I feel a sense of accomplishment and pride after
  I have completed my work on this unit.

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Results Q4
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Results Q6
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Category C Does the team provide optimal
patient care?

• Question 2
• The care team on this unit is committed to
  providing the highest quality of patient care.

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Results Q2
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Category D How does the team work together?

• Questions 3, 5 and 7
• Care team members feel free to suggest ways to
  improve how the team functions.
• This unit and other hospital departments work
  well together.
• The physicians, nurses and other staff on my
  unit/department work together as a
  well-coordinated team.

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Results Q3
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Results Q5
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Results Q7
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Category E How does this work environment
support team development?

• Questions 8 and 11 (Design Targets)
• This unit provides a supportive environment that
  nurtures my professional formation and
  development.
• I am part of an effective work team that
  continuously strives for excellence even when the
  conditions are less than optimal.

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Results Q8
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Results Q8
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Results Q11
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Results Q11
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Analyze Your Results

• Work in your teams
• Analyze your data (or the sample set) to define
  tests of change
• For which categories do you have mostly top box
  results (strongly agree 5s)?
• For which categories do you have the most room
  for improvement (disagree strongly disagree -
  1s and 2s)?

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Actions

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Targeting Innovations to the Team Survey
Responses

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Key Changes Engage Front-Line Staff

• Institute shared governance models
• Empower multidisciplinary teams in work redesign
• Conduct targeted brainstorming activities to
  promote innovation (e.g. snorkel)
• Use storytelling to connect staff to problems and
  solutions
• Employ direct and analogous observation

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Seton Northwest Snorkel to Engage Front-Line
Staff
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Key Changes Optimize Team Communications

• Build staff competencies using SBAR situational
  briefing language
• Model and teach assertive language skills
• Encourage staff to address conflicts effectively
  (difficult conversations)
• Use checklists at key handoffs
• Institute true multidisciplinary rounds (with
  physicians, nurses, and other key clinical
  personnel)
• Employ team training and simulations

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Unit-based Traffic Light System for Staff
Capacity
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Multidisciplinary Rounds Standardized Questions
for discussion

• What problems did the patient have overnight?
• What are the results from previous tests
• What is the plan for the current day
• What is the patients progress towards discharge?
• Are there any questions from the patient or
  family?

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Representative Quotes from Patients and Families

• We have been in and out of hospitals for almost
  18 years, in 3 different cities, more than 7
  hospitals, this team is by far the best we have
  seen, top to bottom. They listen and are so
  compassionate. The care is exceptional.
• Staceys Mom (Crohns patient)

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• The legendary "light" that became a truth is
  that the future of nursing, the gift of caring
  for our patients, for ourselves and for each
  other is upon us and will undoubtedly save lives
  and fulfill destinies for those who take our
  journey.
• Mary J.

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Vitality and The Leadership Role

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Sounds like Change Management to me

• Are you sure this isnt just another ploy to get
  staff to adopt necessary changes?
• How is this experience different ?

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This isnt your Fathers Oldsmobile.

• Once staff complained about an issue with their
  work
• Managers would listen and try to remedy the issue
  
• Issues would be taken to monthly meetings,
  several months go by and they return with the
  solution

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And Now

• Staff recognize and issue and mention it to
  others in department
• They are encouraged to bring the concern and
  their possible solution to the TCAB meeting
• The team discusses to assure the right problem is
  identified and assign a buddy to help develop the
  testing

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Which comes first the chicken or the egg?

• The culture for staff engagement accountability
• Or
• The leadership that not only allows it but
  expects it

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How you lead is what will change

• Get clear on vision what is possible
• Create the environment
• Teach the methods
• Step back
• Get ready to celebrate

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Leadership Characteristics that support
front-line team engagement

• Respect for professionalism of staff
• Role of teacher
• Support from upper management allowing time for
  improvement

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Leadership Characteristics that support
front-line team engagement

• Tolerance for change
• Willing to take calculated risks
• Focus on small tests of change to build trust
• Willingness to have several things going on at
  once

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Leadership Characteristics that support
front-line team engagement

• Personal self-confidence to allow staff to make
  changes
• Being open to staff identifying ways things can
  be different

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Enhance the Culture to Promote Vitality

• Leadership support of shared governance and
  front-line involvement in innovation and design
• Promote professional practice model
• Build trust staff feel confident trying things
  in low-risk environment
• Build a retention-focused environment (all
  managers are Chief Retention Officers North
  Shore Long Island Health System)
• Conduct ongoing assessment of climate (ex.
  Workforce/Team Survey)

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Key Leadership Practices to Promote Vitality

• Singular focus on values and mission
• Establish a safe culture blame-free
  reporting, leadership walk-arounds
• Commitment to talent management and development
  of mid-level supervisors
• Focus on sense-making within the organization
  linking the vision to the work

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Vitality Engaging the Team

• Deep Dive or Snorkel?

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Objectives

• Differentiate snorkel from deep dive
• Develop know how to lead a snorkel

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Deep Dive vs Snorkel

• Deep dive
• 3 days
• Observation
• Analogous observation
• Literature or knowledge review
• Story telling
• Brainstorming
• Rapid prototyping
• Enactments

• Snorkel abbreviated deep dive
• Purpose generate ideas to test and to engage
  staff
• A day or less
• Idea Generation

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Steps to snorkel

• Invite
• Front line staff
• Physicians who care for patients on unit
• Patients
• Other key members of multi-disciplinary team
  including HUCs, patient care techs

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Steps

• 1. What does it mean to transform vs change?
• 2. Engage the heart shared, voluntary story
  telling of best care
• 3. More about the heart shared, voluntary
  story telling of worst experience of care
• 4. Pose question what if? Or what would it
  take to give the best care each time?

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Steps

• 5. Brainstorm changes
• 6. Organize under design targets or themes
  (unless you are conducting a dedicated snorkel)
• 7. Array in a matrix
• Cost v ease
• Time to do v cost
• Involvement of non-unit v cost

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Steps

• 8. Make a plan for testing
• 9. Engage in small tests of change
• Repeat process as needed
• Energy wanes
• Widen the circle of influence
• Engage related disciplines

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Optimizing Team Communication

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Who is the Team ?

• Keeping our patients and their families at the
  center calls us to include them in all
  discussions about their care
• Nothing about me, without me

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Team Members Who to include ?

• Think proximal to patient
• Think more distant or indirectly from patient
• Proximal
• Nurses (all shifts), Doctors (all specialist),
  Therapist, Social Workers, Nutritionist

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Team Members

• More distal
• Such as Pharmacist, order entry clerks,
  admitting clerks, Imaging team, Rehab. Medical
  Records
• The average hospital patient sees more than 20
  staff members every day.

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Team Members

• The average hospital patient receives services
  directly or indirectly from over 15 different
  departments
• Why is it so challenging to get the right
• Information at the right time ?

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Patient-Centered Care

• High Leverage Changes
• Customize care to values, preferences
• expressed needs
• Patients establish daily goals
• Support and involve of patients and families
• Optimize transition to home or other facility
• Create patient-centered healing environments

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Key Changes for Patient-Centered Care

• Physician, nurse and patient discuss goals for
  day and progress toward discharge during bedside
  rounds.
• White boards in patient rooms reflect patients
  goals and medical plans.

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MDRN Rounds Standardized Questions for
discussion

• What problems did the patient have overnight?
• What are the results from previous day tests
• What is the plan for today
• What is the patients progress towards discharge?
• Are there any questions from the patient or
  family?

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Interdisciplinary Rounds

• What are advantages
• All stakeholders speak with patient at same time
• Clarifying questions or callbacks are reduced or
  eliminated
• Reduces cycle time for next steps

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Interdisciplinary Rounds

• What are challenges
• Unlike ICU, there are many, many patients to
  cover
• Some patients are on a more predictable path
• Multiple physicians, multiple rounding times

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Interdisciplinary Rounds

• Where do you start?
• Consider selecting one physician or one
  diagnosis
• Engage key team members based on the specialty

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SBAR Tool

• Situation
• Background
• Assessment
• Recommendation
• One tool for organizing information painting a
  picture over the telephone

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Handoffs

• Nurse to Nurse
• Shift to Shift
• Physician to Physician
• Weekends
• Different Levels of Care
• At time of Discharge

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Handoffs

• Standardize information to share at every
  opportunity
• Consider a template of key information
• to review
• Include family members who are rotating in and
  out with the plan and how they can help

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Representative Quotes from Staff
We were talking the other day about why we took
a pay cut and left Premier Staffing. One thing is
organization.  This hospital seems to be so much
more organized than other places I've worked.
Also resourcesthere is always someone available
that knows. And there is such a cohesive staff
here. Diana F. "This place, more than
any other place, has a sense of teamwork.  I know
I have a strong base of support if I need
help. Susan C I got a warm feeling
when I came here. The RWJ TCAB project let me
know that we were not afraid to change and make
things better.  I feel like we're more
nurse-led than management-led but management
supported, you know?
Krista
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Representative Quote from a Physician

• The TCAB thing has been great. The nurses have
  better communication with the us (the doctors)
  and better communication with the patients. This
  then results in better communication between the
  doctors and the patients. Dr. E

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Optimizing Communications

• Difficult Conversations

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Difficult Conversations

• A difficult conversation is anything you find it
  hard to talk about.
• The dilemma avoid or confront, it seems there is
  not good path.
• Difficult conversations are a normal part of
  life.

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Reference

• Difficult Conversations How to Discuss What
  Matters Most, by Douglas Stone, Bruce Patton,
  Sheila Heen of the Harvard Negotiation Project,
  (1999), Penguin Books, New York

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Difficult Conversations

• There are three parts to a difficult
  conversation
• 1. What happened?
• 2. How am I feeling?
• 3. How does this impact my identity?

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The What happened? Conversation

• Stop arguing about whos right explore each
  others stories
• Why we argue, and why it doesnt help
• We think they are the problem
• They think we are the problem
• We each make sense in our story of what happened
• Arguing blocks us from exploring each others
  stories

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Arguing Without Understanding is Unpersuasive

• Why we each see the world differently
• Different information
• We notice different things
• We each know ourselves better than anyone else
  can
• Different interpretations
• We are influenced by past experiences
• We apply different implicit rules
• Our conclusions reflect self-interest
• Move from certainty to curiosity (are we in the
  intent to learn)
• Curiosity the way into their story
• Embrace both stories adopt the And stance

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Seeing the World Differently

• Two exceptions that arent
• I really am right
• Giving bad news

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Distinguish Blame from Contribution

• Abandon blame map the contribution systems
• Blame is about judging, and looks backward
• Contribution is about understanding, and looks
  forward
• Contribution is joint and interactive

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Intentions vs. Impact

• The battle of intentions Two key mistakes
• The first Mistake our assumptions about
  intentions are often wrong
• We assume intentions from the impact on us
• We assume the worst
• We treat ourselves more charitably
• Are there never bad intentions?
• Getting their intentions wrong is costly
• We assume bad intentions mean bad character
• Accusing them of bad intentions creates
  defensiveness
• Attributions can become self-fulfilling

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• The second mistake Good intentions dont
  sanitize bad impact
• We dont hear what they are really trying to say
• We ignore the complexity of human motivations
• We aggravate hostility--especially between groups

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Avoiding the first mistake

• Disentangle impact and intent
• Hold your view as a hypothesis
• Share the impact on you inquire about their
  intentions
• Dont pretend you don't have a hypothesis
• Some defensiveness in inevitable

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Avoiding the second mistake

• Listen for feelings, and reflect on your
  intentions
• Listen past the accusations for the feelings
• Be open to reflecting on the complexity of your
  intentions

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The Feeling Conversation

• Feelings matter they are of the at the heart of
  difficult conversations
• Have your feelings (or they will have you)
• We try to frame feeling out of the problem
• Unexpressed feeling can leak into the
  conversation
• Unexpressed feeling can burst into the
  conversation
• Unexpressed feeling make it difficult to listen
• Unexpressed feeling take a toll on our
  self-esteem and relationships

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A Way Out of the Feeling Bind

• Finding your feeling learn where feelings hide
• Accept that feelings are normal and natural
• Recognize that good people can have bad feelings
• Learn that your feelings are as important as
  theirs

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A Way Out of the Feeling Bind

• Describe feelings carefully
• Frame feelings back into the problem
• Express the full spectrum of your feelings
• Dont evaluate--just share
• Express your feeling without judging,
  attributing, or blaming
• Dont monopolize both sides can have strong
  feelings at the same time
• An easy reminder Say I feel....

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Impact on Identity

• Three core identities threatened by difficult
  conversations
• Am I competent?
• Am I a good person?
• Am I worthy of love?

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Identity

• Three things to accept about yourself
• You will make mistakes
• Your intentions are complex
• You have contributed to the problem

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Create a Learning Conversation

• Whats your purpose? When to raise it and when to
  let go
• To raise or not to raise how to decide?
• How do I know Ive made the right choice?

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Create a Learning Conversation

• Three kinds of conversations that dont make
  sense
• Is the real conflict inside you?
• Is there a better way to address the issue than
  talking about it?
• Do you have purposes that make sense?

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Create a Learning Conversation

• If you raise it three purposes that work
• Learning their story
• Expressing your views and feelings
• Problem-solving together
• Stance and purpose go hand in hand

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Adopt some liberating assumptions

• Its not my responsibility to make things better
  its my responsibility to do my best.
• They have limitations too.
• This conflict is not who I am
• Letting go doesnt mean I no longer care

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Putting it all together

• A Difficult Conversations Checklist
• Step 1 prepare by walking through the three
  conversations
• Step 2 check your purposes and decide whether to
  raise it
• Step 3 start from the third story
• Step 4 Explore their story and yours
• Step 5 problem-solving