Joanne's Journal - Thursday, February 1, 2018
Workarounds…why I kind of like them.
I have started my executive leader rounding, (See this story for more information on that), and one of the questions I am asking the staff is about their workarounds. If we want to be a great organization for our patients, we have to critically ask ourselves if our processes for getting work done are effective or just the opposite. Workaround behaviors are those that circumvent or temporarily ‘fix’ an evident or perceived workflow block. Workplace workarounds are used to solve problems; sidestep ‘problematic’ rules; bypass blocks in efficiency created by safety mechanisms; address poor workflow design and organizational and system issues.
I want to emphasize that some of our processes are very important from a safety or regulatory perspective, and workarounds can create potential risks. However, many of our processes that are simply “how we do things” can be improved. This happens at a lot of organizations, not just at D-H.
According to a 2006 study (Operational Failures and Interruptions in Hospital Nursing), data suggests that hospital nurses experience an average of one "operational failure" per hour. Dealing with them takes valuable time away from patient care—an average of 33 minutes per nurse per 7.5-hour shift. Have you ever shadowed a nurse? I did for 4 hours, and I think I put in 10,000 steps on my Fitbit. Work-system problems affect everyone in health care. The cumulative time spent tracking down necessary items quickly becomes staggering. Ironically, the true magnitude of work-system problems remains hidden because frontline health care professionals are so good at working around them.
We have lots of assumptions about how work gets done that don’t mirror exactly what happens. After all, during the day-to-day grind, we don’t question how we do the work, we often just do it.
We have great resources here that we could deploy to look at our most vexing problems and share them broadly. Some great examples are how the Lab has used Lean Six Sigma principles to streamline their work flow. In fact, the entire laboratory space renovation that occurred in 2016 was based on a Lab LEAN Team that studied workflow and applied LEAN process improvement principles to recommend relocation of Lab sections and the precise placement of instruments in an effort to streamline processes and improve Lab turnaround times. A smaller, more recent effort, is a Greenbelt project, led by Microbiology in conjunction with the Operating Rooms (OR) to improve the accuracy of Microbiology orders and specimens submitted in proper specimen containers from the OR with the aim to reduce unnecessary rework and improve care.
What can we do to move from a workaround culture to a team that uses operational failures as opportunities for rapid learning and systems improvement? Managers should encourage staff to communicate when our process is getting in the way of efficient work and timely care. We need team leaders that say “Yes” and can remove underlying causes, allowing experimentation with solutions. Many of these principles are taught through our very own Value Institute Learning Center.
Our ability to be successful will depend on our organizational culture…the one we want to build and evolve together. Culture is the intangible sum of our history, principles, traditions, actions, language, perks, policies, accomplishments, failures, procedures, ambitions, fears, expectations, values, benefits, and leadership.
We need to constantly pulse check our culture. What’s working? What’s not? What’s shifting, and are we okay with it? Subtle pushes, pulls, or course corrections ensure that the culture is constantly being shaped. It is anchored in our principles/values…things like integrity, honesty, trust, respect, and accountability. So as we embrace getting better, not just bigger…we need a culture that is open to constantly trying to make our processes both safe but also efficient. As we craft activities that speak to the heart of our purpose…I can imagine a list like this:
- Mission first: Doing the right thing every day.
- Value and respect your colleagues and your patients.
- Step into the arena…be a leader.
- Everyone has a role. Know what your role is and how it fits into the rest of the team.
- Get stuff done.
I look forward to working with all of you to fix what is broken, to continue shaping our culture and crafting our future. Let me know what you think? Do you have workarounds in your area? Send a message to Office.of.the.CEO@hitchcock.org.
Provider Ambassador: Angela Nelson, MPH, APRN, CNM
Provider Ambassadors for Patient Experience—all Dartmouth-Hitchcock (D-H) providers themselves—provide coaching and peer-to-peer support in a collaborative nature. Through peer-to-peer observations and mentoring, the ambassador team partners with a provider in a reflective, thought-provoking and creative way to observe, talk through, inspire, or simply make small changes in style or behavior that can have a significant and lasting impact on the relationship with his or her patients and colleagues.
Angela Nelson, MPH, APRN, CNM, D-H Concord Obstetrics & Gynecology, says when she heard about the Provider Ambassador program, she thought it was a great idea for providers to help other providers communicate with their patients. She’s been involved in the program for about three years.
“My favorite part is working with providers who need to improve their personal connection with patients,” she says.
Nelson remembers one of her first coaching experiences, which has helped her guide subsequent providers. “I was still fairly new at coaching, and this physician’s specialty was in an area I knew nothing about. I admit I felt intimidated at first. This physician was clearly brilliant and quite intelligent, but patients repeatedly said they felt a lack of a connection.” she says. “When I shadowed her with several of her patients, she came across to me as very shy and reserved. She was quiet, business-like and never smiled at her patients or co-workers. I believe this can be interpreted as cold and not caring. After spending a day with her and talking, I came to understand that she truly did care about her patients, and invited her to come and shadow me with my patients.
Shortly after, her supervisor said they saw a complete change in this clinician with her co-workers and her patient satisfaction scores improved quite a bit. At first, I had been intimidated, so getting this feedback from her supervisor was really encouraging to me.”
Nelson says when she is assigned to coach a provider, she will look over their patient satisfaction scores and patient comments to get a sense of how the provider is perceived by his or her patients.
Dartmouth-Hitchcock Kicks-off American Heart Month
February is American Heart Month and Dartmouth-Hitchcock (D-H) will be recognizing this special month with a number of heart-healthy events throughout the system, as well as sharing heart health stories and information on the D-H website and social media channels.
- D-H Group Photos - To kick-off the celebration, all D-H physicians and staff are invited to wear red and be part of a fun group photo that shows our support for Heart Month. Photos will be taken on the following days at these times and locations:
- D-H Lebanon: Thursday, February 1. Meet on Level 4 above the Main Rotunda from 11:45 to 11:55 am. The photo will be taken promptly at noon.
- D-H Concord: Friday, February 2, at noon in the lobby.
- D-H Manchester: Friday, February 2, at noon in the lobby.
- D-H Nashua: Friday, February 2, at noon in the lobby.
- Annual Snowshoe Event: Tuesday, February 6
All community members and staff are invited to participate in the annual snowshoe event in Lebanon sponsored by D-H Heart and Vascular Center and Live Well/ Work Well (LWWW). Meet at Café B at 5 pm and bring snowshoes and a headlamp. Participants are also encouraged to wear red to show your support for the American Heart Association’s Go Red for Women movement. More details can be found here.
- "Get Heart Smart!" Symposium: Thursday, February 22
Learn how to prevent cardiovascular disease in youth and throughout your life by attending a free 90-minute cardiovascular health discussion, featuring D-H cardiologists Drs. Kalyan Ghanta, Gerard Dillon and Richard Hayes from 6 pm to 7:30 pm at Dartmouth-Hitchcock Manchester. Discussion topics include: understanding cardiovascular risk factors such as diabetes, high blood pressure and smoking; identifying and managing risk factors with your doctor; and recognizing the symptoms of a heart attack or stroke, which are different for men and women. More details can be found here.
- Facebook Live: A D-H cardiologist will be taking your questions about heart health in a February Facebook Live. Check D-H’s Facebook page regularly for more information about this event.
- American Heart Association’s Fifth Annual Upper Valley/Lake Sunapee Go Red for Women Luncheon – Friday, February 9. D-H CEO and President Dr. Joanne Conroy will be the keynote speaker. The event is being held at the Hanover Inn in Hanover, NH. Her topic will be “Recognizing and Preventing Stroke and Heart Disease.” The lunch and program are at noon, and before that, there will be education breakout sessions with D-H cardiologists and neurologists, as well as a panel discussion, silent auction and vendor fair. To learn more and to register go here.
Our Patients. Their Stories. Cassidy Hankins
“I’d heard all the bad stuff they tell you in school—like ‘Don’t do drugs,’” says Cassidy Hankins of Canaan, New Hampshire. “But no one actually sat down and explained to me what can really happen if you take this stuff.”
Hankins’ addiction to Percocet, a painkiller generically known as Oxycodone, started at 16 when her boyfriend at the time introduced her to it. Soon she learned the dangers of using it. “I knew what a high felt like,” she says, having smoked marijuana, “but this is like a hundred times more. Percocet makes you just sit there, and you can’t really move or do anything.”
Her boyfriend then introduced her to heroin, which she experimented with by snorting it rather than injecting it intravenously with a hypodermic needle. While the high was more intense, her fear of needles kept her from experiencing an even bigger high. “I’ve seen people who shoot it, and they look instantly dead,” she says.
A month later, she broke up with her boyfriend and no longer had access to heroin, but a new boyfriend led her right back to taking Percocet. Regular access to the 30 mg pills, among her friends wanting to have a good time, made Hankins’ habit difficult to break.
“It turned into an everyday thing,” she says, “I took Percocet for so long that my body got used to it and needed it. After a while, you don’t get high from it anymore. You need it just to feel normal, to do whatever it is you need to do.”
When pills became scarce, withdrawal symptoms like hot and cold sweats and existing chronic back pain set in. “It was unbearable. I couldn’t move, couldn’t sleep, couldn’t do anything,” she says. “It’s like someone was literally sticking a knife in my back.”
The Percocet abuse continued for five years, then Hankins began a relationship with a man who understood how difficult it would be to quit, having gone to rehab to overcome his own addiction. “Being with someone who understood and who was clean was a step in the right direction for me,” she says.