Five Lessons Learned in 10 Years of Experience:
- Invest in doing it right
- Culture matters
- Leaders need to lead
- Create a culture of psychological safety
- Sustain new habits with group coaching from certified coaches with proven experience
“Blame has an inverse relationship with accountability. Accountability by definition is a vulnerable process…blaming is one of the reasons we miss our opportunities for empathy.” Brené Brown
The Institute of Medicine (IOM) released its landmark report, To Err Is Human, in 1999 and reported that as many as 98,000 people die in hospitals every year as a result of preventable medical errors. In 2016 a Johns Hopkins School of Medicine study revealed that the IOM report may have significantly underestimated the problem, putting the actual number closer to 250,000 – 400,000.
A recent NIH report estimated 80% of serious medical errors involve miscommunication during patient transfers. And the Joint Commission International found 80% of serious medical errors were the result of miscommunication between caregivers during patient handovers.
Common communication challenges and shortcomings include:
- Inadequate handovers or transitions of care
- Poor discharge planning and inadequate or unclear patient instructions
- Language problems such as limited English proficiency, literacy, and health literacy of patients
- Cultural barriers and misunderstandings
- Age-related challenges
- Errors in test results and medical orders
These studies have consistently shown that the primary cause of errors in healthcare is due to communication problems and that the great majority of communication problems stem from fear of speaking up. The demographics of health care have changed dramatically, but unfortunately, the legacy of command and control persists. Cultural change is difficult and perhaps the biggest challenge leaders face today.
We spend a lot of time in our programs discussing the importance of psychological safety and exploring various tools that are effective in establishing an environment in which conflict can become healthy and productive.
To quote Amy Edmonson, “Cheating, and covering up our natural by-products of a top-down culture that does not accept “no”, or “it can’t be done” for an answer, but combining this culture, with a belief that a brilliant strategy formulated in the past will hold indefinitely into the future, becomes a certain recipe for failure.”
Participants are encouraged to explore the challenges to cultural change including:
- The traditional physician cultural indoctrination of autonomy, as in, “MY patient”.
- The malpractice environment that reinforces this “ownership”
- The shaming of mistakes
We introduce the work of Brene Brown and Amy Edmonson to introduce a different way of looking at mistakes and help them understand the difference between guilt and shame. Participants have the opportunity to explore ways to establish and maintain trust, reframe negativity, and encourage participation in problem-solving. They learn how to manage their own assumptions and encourage others to do so as well.
If you are looking for ways to create a culture of safety in today’s changing world, reach out to us today.