Tuesday, July 12, 2016


               In a random search for articles on patient safety, I ran into one I had not read before by Dr. Ronda Landers DNP, RN titled “Reducing Surgical Errors: Implementing a Three-Hinge Approach to Success”. I was intrigued because she tackles three challenges we face in instituting a Safety Program:  the CHANGE AGENT (getting the right person in the right place at the right time), TEAM COHESIVENESS (getting the right team in the right place at the right time) and QUALITY MONITORING (getting the right data at the right place at the right time). Effectively instituting the three of these can be the ultimate challenge any facility will face. 

Regarding the CHANGE AGENT, Dr. Landers, states that “this person should be the individual who drives people to action and changes followers to leaders, who may then also become agents of change.” She recommends that a nurse holding a doctorate in nursing practice (DNP) would be the “optimal choice for the leadership and oversight of the safety program.” The most effective person in this position should be able to appropriately address all questions and myths regarding patient safety.

Regarding the TEAM COHESIVENESS, Dr. Landers states that this person “is a key element for building team cohesiveness”.  In addition she states that “the leader should promote a working culture that cultivates empowerment, communication and respect among team members.”  “Leaders should continue to support the staff by being visible and using an established feedback system to listen to staff member concerns, facilitate interdisciplinary communication, actively resolve conflict, make adjustments, and empower team members”. To this end I say AMEN! This is so true. Leaders should do all these.

Finally, regarding QUALITY MONITORING, Dr. Landers states that “Monitoring of these measures is a daily continuous process with reporting quarterly or as needed. The main goal of a quality improvement initiative is to identify trends and develop and implement prevention processes that reduce the risk of similar errors occurring in the future. A culture of tolerance and n0n-retribution should be created so that surgical staff member do not fear reporting incidents or near misses and all team members can learn from them. Leaders play a vital role in creating an atmosphere in which there is open dialog without punitive action.”

At the end of the article, I felt that this synopsis provided the base framework in which to institute a safety program. At the end of the paper I found that, in principle, I agreed with her approach to the subject but I immediately thought of two literature pieces I recently read on this exact topic which merited some further consideration.

The first was ‘Effective Surgical Safety Checklist Implementation ‘ by Singer and Gawande’s group from 2011 in which the surgical teams admitted that in order for them to have buy in they needed an “implementation leader”; that is, someone they trusted and knew. They stated that they would not have listened if the facility brought in a ‘quality person’.

The second piece was a letter from General Surgery News November 2015 Never Event’ Nightmare Before Christmas’ by Linda Wong MD. In this letter Dr. Wong describes her encounter after she saved a patient who was dying from exsanguination from a ruptured hepatic tumor, but left the OR with a single sponge behind (out of 120 used). In the end she states that she was humiliated in spite of her heroic efforts.
I had questions for Dr. Landers:

  • Why do sentinel events still go unreported? It is FRUSTRATING but a reality that they seem to occur but are not reported. Does anyone understand why that is?
  • Based on your experience and knowledge, how do we implement a non-punitive system? It sounds easy but as I will get to, putting that into practice often seems difficult in some institutions and impossible in others. There seems to be a disconnect between the goals in reporting adverse events and reality especially since each sentinel event is a likely litigious event.
  • You say it is ideal for staff members who are familiar with each other to work together to maintain a positive environment but is that possible in the age of cross training, hiring problems, etc? Ie is it better to rotate folks so they are at least somewhat familiar with the teams they may be on or better to leave ‘em be so they really know each other and then when there is a call in, you have to pull someone in who has little experience in that area?
  • How do we really know folks are paying attention to the checklist? I mean we just hit the “I agree button” when it is time to renew software and NOBODY is paying attention when the flight attendant is telling us how to not die should the plane land in the water?
  • From what I am reading, shouldn’t the safety manager be a part of the teams or at least be experienced in those areas and be respected by the teams?
  • Shouldn’t the safety manager have proven leadership experience in a team that has proven success in safety?
  • You state that the “DNP is thoroughly prepared, uniquely positioned and well suited to translate current research and best evidence into the practice setting to enhance health care outcomes”. I agree, BUT how does a successful hospital assure they hire someone who knows the research, understands patient care as it occurs in reality and has successful leadership experience? Obviously you have to have a “quality person” but how does that person integrate with the safety process so that the teams they are trying to implement improvement processes in, feel that it is the team who is implementing these and not someone the administration sent in? This is really tough for hospitals I think.
  • Finally, how do we avoid providers from feeling persecuted? I understand that the safety/quality teams do not intend that as a consequence, but as the letter referred to this sense of persecution appears to result from these meetings on a frequent basis?


I am fortunate that Dr. Landers answered my questions as follows:


Thank you Dr. Lipshy! I wish that I had all of the answers, I don’t. However I do enjoy sharing my experiences and thoughts.


Why do sentinel events still go unreported? There is no single answer. However, it does seem to me that many are “talking the talk, and not walking the walk”. Although, healthcare governing bodies are encouraging providers of care to speak up, as they should, in actuality often the workplace environment remains somewhat intimidating in regards to human error. Primarily, fear of reporting is motivated by what the consequence may be such as humiliation among peers, administrative reprimand, job loss, and/or litigation.


How do we implement a non-punitive system? Change will occur when the focus is shifted away from the “human” and centered on what can be learned from the “error”. Data related to error is invaluable for future success. It may very well save lives. Based on my experience, a non-punitive working climate has to be cultivated and it begins with building trust. Trust or distrust is communicated in basic ways. Leaders and managers always communicate their attitude and expectations whether they intend to or not. Open, honest, and supportive communication is imperative in gaining trust among teams. A collaborative climate is crucial and especially interdisciplinary. Most important, when an error does occur and is reported, it should be handled as promised. Trust must remain intact. If the focus is kept on what is learned, it can be highly motivational for the whole team, even somewhat liberating.


Is rotating staff a good idea? Cross training is advantageous. When I hired a new employee, they were oriented in each area of the ambulatory surgery center; perioperative, OR, and PACU. However, they mostly worked in the position they were hired for. I found that teams familiar with each other worked much more effectively and their energy was positive. Importantly, they anticipated each other’s needs. Additionally, I believe a good practice is to include the team during the interviewing process. Allow them to meet and talk with the candidates then get their feedback.


How do we really know folks are paying attention to the checklist? We don’t. Not unless we are all keeping a watchful eye. The team members play an important role with keeping things real. Worry less about checking the box and more about consciously doing it. Dance and Sing it out loud if you have to, but just do it. I liked your analogy related to not paying attention to the flight attendant’s instructions on how not to die when the plane crashes in the water. I have held many different titles in the work setting and my most favorite was “Storm Anchor”, given to me by a surgeon and Medical Director that loved to sail. My leadership style is to empower teams to sail on their own but remain present just in case a storm arises, then act quickly to stabilize the situation. I think a good leader is an active participant, one that engages in dialogue with the team to share ideas and help make decisions. In addition, they should be the one that always pays attention to the flight attendant when instructions are given!


Should the safety manager be a part of the teams or experienced in those areas and be respected by teams? And should they have proven leadership experience in safety? Absolutely! “Nothing about us, without us, is for us”.


How does the hospital assure they are hiring the right person? In the three hinged approach, I used the DNP as the Change Agent for several reasons, a few being: 1) the DNP curricula is similarly consistent among universities and colleges especially related to teaching evidence-based practice models, how to perform literature reviews, how to interpret research studies, and how to apply best evidence in the practice setting, 2) Their Capstone is based upon projects centered on improving areas in the practice and academic settings (quality improvement), and 3) Leadership and management strategies are thoroughly taught. Are all DNPs the most qualified person? I hardly think so. It’s the combination of formal education, experience, skill-set, and personal characteristics that make for a successful leader. Healthcare environments are complex, uncertain, and often changing. Managing information is key. Leaders must be effective communicators. I agree, finding the right “quality person” can be really tough for hospitals. But I also think, in part, they are responsible for the grueling challenge. Unfortunately, the hiring structure has changed over the past few decades. There are too many steps in the process and the key stakeholders that should be involved from the onset are often overlooked; the TEAM ITSELF. Today, administration tends to rely on corporate recruiters, numerous telephone interviews, and/or Human Resource departments to find the right person. It leaves me to wonder just how many good candidates are missed because we are depending upon people to fill positions that have no true understanding of or they have no stake in. It seems so obvious, include the people that are mostly affected by the change and empower them to be a part of the process.


Your last question is very important but not easily answered. How do we avoid providers from feeling persecuted? Healthcare leaders have the opportunity to change the tone in communication interaction. As healthcare continues to grow and become more complex, the need for humane behavior among all disciplines is crucial! They don’t want to be bullied and dehumanized and nor should they. People want to be treated as a “human being”. The core of Dr. Bonnie Batery’s Humanizing Nursing Communication Theory is “communing” and the elements include: trust, self-disclosure, feedback, and listening. 


Interestingly enough, this week the Institute for Healthcare Improvement featured a post from Humans of New York, titled ‘What We’re Reading: Surviving the Trials of Residency’. The post is written by a medical resident who shared his story, “I guess I thought that everyone would be compassionate, and would help each other. But the stress just erodes people. There’s a lot of tension and anger. We’re taught that 80 hours per week is normal and shouldn’t be questioned.” Then a nurse chimed in saying, “Nursing school is learning how to save others’ lives without taking your own”. Perhaps leaders and providers of care should begin with what I believe is the most valuable piece of communication, “listening”. And let's not forget, mutual respect.  (see my interview with Amir Erez on this topic at  http://crisislead.blogspot.com/2016/06/impact-of-incivility-on-team.html)



"In the end, trust is the key!"
"I believe that the team is important even down to the hiring process!"


Landers R. Reducing Surgical Errors: Implementing a Three-Hinge Approach to Success. AORN JOURNAL 2015; 101(6):657–665


Conley DM, Singer SJ, Edmondson L,  Berry WR,  Gawande AA. Effective Surgical Safety Checklist Implementation. Journal of the American College of Surgeons. 2011; 212(5):873–879.

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