On February 17th, Ruth will speak on the nationally distributed AONE webinar: Why Nurses Still Must Learn to Delegate, and How.   To register, the link below will be helpful:

http://online.krm.com/iebms/reg/reg_p1_form.aspx?oc=10&ct=00300263&eventid=16506

Join the webinar and help support AONE!

Summary

• Analyze current evidence related to missed or omitted care, delegation, and supervision.
• Rate your department’s skill level in delegation, supervision, and teamwork leadership.
• Trace the impact of poor teamwork to HACs (Hospital Acquired Conditions).
• Plan next steps to structure a mental model and plan for successful RN team leadership.

This is the text of the Oakwood press release! Congratulations Diane, one of our RROHC Facilitators!
Ruth Hansten and RROHC faculty

Oakwood Featured in Nursing Textbook Oakwood nurse executives provide their expertise in a university textbook so that future nurses can learn from Oakwood’s Relationship Oriented Care model. Oakwood’s nursing expertise is now available to nursing students nationwide. Director of Nurse Recruitment & Retention Diane DiFiore, RN, MSA, and Sandy Schmitt, RN, BSN, Manager of Nursing Development, were quoted in Critical Thinking Tactics for Nursing, a respected university nursing textbook written by two Eastern Michigan University educators. Diane and Sandy were interviewed about Relationship Oriented Care (ROC), the patient- and family-focused care model used by nurses throughout the system to provide better care at the bedside. For more information, visit the News section of oakwood.org. Kudos to Diane and Sandy!

A study by researchers at the University Wisconsin School of Medicine and Public Health reported in Family Medicine that when physicians expressed concern or empathy for the patient,  they experienced one fewer day of cold symptoms than those who did not perceive care provider empathy.  There was a boost of the patients’ immune systems with a direct relationship between the MD’s empathy level and the patients’ level of IL-8 (which reportedly summons immune system response).   This was reported by Harvey Black in the Nov/Dec 2009 issue of Scientific American Mind. 
This research follows our premise that there is a healing effect in healthcare that treats the individual patient with compassion. This supports the Relationship & Results Oriented Healthcare Program’s 3 elements and 10 steps.
We applaud the University of Wisconsin for conducting this randomized controlled trial.

Ruth Hansten and the RROHC Team

Wow! We are impressed! Our RROHC-er clients, Glades General has moved to their new medical center, Lakeside, AND we just heard that they have had ZERO Ventilator Associated Pneumonias over the last year! They are very humble about their stellar record with hospital acquired conditions (HACs)!  Congratulations!

Ruth Hansten and the RROHC team

 What you Permit You Promote: How are we leading by silence?

 In the RROHC Facilitator training we discuss accountability in depth and we revisit this topic in our RROHC monthly conversations. What Karlene Kerfoot has stated in the lead of her article…”What You Permit, You Promote” she reviews an article by AG Lafley in Harvard Business Review (“what only the CEO can do” HBR 2009 87 (5): 54-62.) I quote Karlene in her column in the July-August 2009 Nursing Economic$ (vol. 27, 4: 245-250): “The best outcomes for patients happen in tightly synergized teams. When we allow deviation from evidence-based practice and from behavior that prevents people working together in tightly synergized teams, we set the stage for a dangerous situation for patients and an impossible culture for people to work safely. If leaders permit practices and behaviors that will not lead to safety, then they are promoting mediocrity and unsafe working conditions. (p. 245)” “When sloppy work is permitted on the excuse that the nurse is new or confronting personal problems, others in the organization quickly learn that excuses will be accepted and they can lower their standards. What you permit, you promote.”(p. 250). Alleluia! YES. In the level 1 program we discuss the Silence Kills study and the number of staff and leaders that are willing to confront other colleagues with care they consider substandard. Only 3% of staff confronted, 16% of managers dealt with incompetence. OH MY. This stops me cold. Managers AND staff are all accountable to the public that we serve. (www.silencekills.com) It took me almost a year as a new manager to understand the large impact of my behavior on others. (Maybe longer for the lesson to stick!) EVERYTHING one does or says becomes a part of the soul of that organization. We must as leaders gird our loins and our minds and be clear about our impact on the culture of our organizations. In the RROHC program we provide a structure for hospitals and other healthcare organizations to use to establish clear expectations for relationships and a clear focus on results, as well as a set of 10 best practices. It is up to the organization to provide the training and the other framework (job descriptions, coaching for the outcomes and care we can all be proud of. Thank you Karlene for your insightful and timely column in Nursing Economic$!

Ruth Hansten

In a regular column in Nursing Economic$, Karlene Kerfoot  examined several sources about leadership and decision-making.  (Because she wrote this in March/April 2009, she would not yet have had the benefit of Philip Hansten’s superb  Premature Factulation book!)  She reviewed Brafman and Brafman’s book (20087) Sway the Irresistible Pull of Irrational Behavior; Campbell, Whitehead, and Finkelstein’s 2009 article in Harvard Business Review about “Why Good Leaders Make Bad Decisions” (87(2):60-66; and Burton’s 2008 book On Being Certain: Believing You are Right Even When You are Not.

Many of you in the RROHC community are leaders in title; we would assert that ALL of you are leaders.  People in your organizations look to you to help create a better healthcare delivery model and to assist them in learning the 10 best practices.   As those who are seen as able to set a course to achieve a vision of better outcomes, we need to be able to examine our own critical thinking.  In Karlene’s article, she discusses that the pattern recognition that we develop as we become expert can also derail us, even though we must categorize or create patterns with all the information that flows into our consciousness in some manner.  We all have blind spots, and coaching helps us to acknowledge these and deal with our tendencies to react in one way or another more effectively.   Because of our closely held beliefs we can tend to react in emotional ways due to the primitive connections in our brains.  We devalue any ideas that don’t stack up in favor of our predetermined solutions.   Three “red flag” conditions admittedly affect our reasoning:  Conflicts of interest;  attachments to people, places, or things; and misleading memories. (Kerfoot cites Campbell, Whitehead and Finkelstein related to these red flags).  In order to avoid the contamination of our personal foibles and issues, a leader must:

1) Encourage dissenting opinions:  For example, if someone in a class states that using the patient-focused interview is not possible, listen and engage them in figuring out ways for them to experiment with the skill.  See how their experiments work out. It only takes one experience of discovering that what a patient’s priority is…is not the same as the healthcare team’s priority…to make a believer out of nurses who scoff at this idea.

2)  Discuss your own “red flag” issues:  ask someone for fresh ideas and outside opinions especially when potential conflicts of interest appear.  We all have misleading memories from our past…especially those that are emotionally charged, and we all have made the mistake of considering the effects on special people before considering a problem devoid of the personalities involved.(Well maybe you haven’t but I have!)

3)  Admit our own mistakes: If one 10 minute session of education on RROHC practices did not really change the practice in your department…..even though we may believe that our staff is “already doing this so it shouldn’t be a big change”…then admit the mistake and go forward with a new plan.

In terms of our RROHC leadership, and especially as we attempt to create more effective interdisciplinary teams, we are all too biased, too quick to judge based on our past experiences and patterns of thought.  As leaders, we must guard against professional stereotyping and other thought errors that could be absorbed by those we teach.   Coaching is one of the methods we recommend  to develop thinking partners and habits of reflection to continually improve our leadership.

Ruth Hansten

(The Neuropsychology of Good Leaders Making Dumb Mistakes” Karlene Kerfoot, Nursing Economic$ March/April 2009, Vol. 27, #2, p. 134-135.)

Failure to rescue  (FTR) is defined as the inability to save a patient’s life after development of a complication that was not present on admission (Clarke, S.P. :Failure to rescue: lessons from missed opportunities in care.  Nurs Inq 2004:11 (2):  67-71) A study by Kathleen Bobay, Karen Fiorelli, and Alfred Anderson in 5 midwestern hospitals showed a lower level of FTR (.03%) than had been noted in other studies.    For example, Needleman et al. showed that almost 20% of elective surgery patients developed potentially preventable complications, and as many as 1.6% died from those nursing omissions/errors.  Nurses with a higher level of expertise are suspected to be more vigilant regarding potential or emerging issues and prevention of complications.  What interested me in this study was the non-technology-based and simple changes that occurred in patients to herald their potential complications!  The subtle changes were in blood pressure, heart rate, respirations, temperature, neuro status and urine output.  These changes had occurred up to 3 days prior to the patients’ transfers to ICU.   What this study infers is that if nurses really were able to delegate and supervise appropriately, and actually reviewed  and analyzed the data the NAs provide, we would save many lives.  The RROHC  10 practices include the necessary communication steps to be certain that these FTR are eliminated. 

For more information, Bobay K, Fiorelli K, Anderson A.  Failure to Rescue: A Preliminary Study of Patient Level Factors, J Nurs Care Qual  2008  vol 23: 3:  211-215.

Ruth Hansten

In a recently published book by Dr. Philip Hansten,  Premature Factulation: The Ignorance of Certainty and the Ghost of Montaigne, (Philoponus Press 2009), the author explores the philosophy of thinking and decision-making.  In my critical thinking doctoral research that informs the six step critical thinking problem solving model and the way in which the RROHC faculty guide the learning process for expert practice, this Dr. Hansten would recommend Premature Factulation for any serious thinkers…who are “thinking about our thinking to improve our thinking,” to paraphrase Richard Paul’s  critical thinking definition.   In our six step problem solving model, we ask each participant to reflect.  Reflection is one of the most basic and fundamental methods for us to improve the way we solve problems or to improve clinical judgment.  We ask you to consider how your own frames of reference, based on your own experiences, may affect your ability to seek new ideas about the reasons that problem exists.  Dr. Hansten discusses common reasoning errors in detail.  One of the errors I discover in some hospitals and nurses is “all or none” thinking.  For example, if the supervisor said “no, we can’t have more staff” that is sometimes the end of the problem solving for the shift, and staff don’t think beyond “no” to how can we do this better? What else could we do to meet these particular patients’ needs?  A close second is “we have always done it this way.”  I suspect as healthcare reform comes around the bend that we have to go beyond the old solutions and continue to reflect on how to best meet the patients/family’s needs in new ways.   I highly recommend this provocative book!  www.philoponus.com or www.amazon.com

By the way, premature factulation is “the process of coming to conclusions without adequate study or contemplation; usually applied to complex concepts or situations.” (this phrase was coined by Dr. Philip Hansten.)

Mark Neill and Nena Saunders wrote an article in JONA in September of 2008 about the Salt Lake City VA’s excellence, with their success based on the servant principles as described in a book by Spears (Insights on Leadership: Service, Stewardship, and Servant Leadership, 1998, John Wiley & Sons).  The ideas behind servant leadership are ancient …and absolutely true to the ideals inherent in the RROHC program.  The 10 principles:  Listening, Empathy, Healing, Awareness, Persuasion, Conceptualization, Foresight,  Stewardship, Commitment to the Growth of People, and Building Community…all these are concepts and values we have woven into the 10 steps of RROHC and our ongoing 3 level certification program.   Conceptualization is missing in many non-RROHC hospitals today.  Staff struggle to find meaning in their fragmented and chaotic work days, and they do not see their practice as a whole and healing endeavor based on a framework of “A Day in the Life of an Expert”.  In many healthcare organizations, there is no unifying language or even a clue as to a model for care throughout.   We are continuing to share the RROHC program principles with healthcare improvement organizations across the nation such as IHI and the Advisory Board.  We are fortunate to be able to serve our communities by clarifying the important work that we all do!

Ruth Hansten

Today on the Level 2 RROHC Facilitator coaching call, several recommendations emerged from the group, related to engaging physicians in the RROHC processes.
1) As RROHC is introduced, inform key physician leaders through existing committees such as the medical executive team or subspecialties groups.
2) Always consider: What’s in it for them? How could RROHC impact their lives? In addition to the obvious improvement in patient care outcomes, what about such issues as happier nursing staff, happier patients/families (taking less physician time to voice complaints), fewer telephone calls from nurses with queries (nuisance calls) due to improper understanding of the patient’s orders, fewer (or shorter in duration) patient trips back to the hospital or physicians office due to patients not understanding discharge instructions, overall:  more smooth, streamlined care due to better understanding by other disciplines of the physician’s plan of care.  An easier home life for busy physicians? You bet!
3) Results such as better patient satisfaction with the physician’s care (if measured by your facility), better lengths of stay, better clinical outcomes and less recidivism (or readmissions) have been noted at many RROHC facilities. Many physicians are competitive, and data being displayed in reference to other practitioner’s data will often motivate a physicians approach to bedside manner!
4) Evidence based practice! We are happy to share with you the slides we use to instruct doctors regarding RROHC and methods for better patient/physician/family relationships, with the research studies noted on each slide. We would also recommend current articles in the news such as a recent NYTimes article by Paul Chen, MD:
| July 30, 2009
Doctor and Patient: Treating Patients as Partners, by Way of Informed Consent
By PAULINE W. CHEN, M.D.
The medical consent process can be a way to strengthen the bond between patients and physicians.

5) Unit and department managers must address RROHC and WIIFM (What’s in it for me?) for the physicians that frequent their areas, to describe how nurses in the level 1 program will be requesting input as to their communication styles and effectiveness, and the impact of RROHC as nurses discuss the patient/family’s short and long term goals with the patient on a daily basis. Leaders may need to visit the offices of key stakeholders and physician leaders to continue the education process.
We know in our hospitals and departments in which physicians have wholeheartedly accepted and endorsed RROHC concepts have reaped excellent results! We invite other experiences and suggestions to add to our blog posting!
Thank you!
Ruth and Kimberly