Raising the System IQ: The Non Punitive Environment

1
Raising the System IQ The Non- Punitive
Environment
June 9th, 2006
Presented by Stephen E. Prather, M.D.
2
Objectives Covered

• Understand the need for a non-punitive culture
• Introduce integrative Quality (IQ) as a solution
• Evaluate the Health of our quality community
• Suggest a competition for non-punitive
  communication support the IQ game

3
Integrative Quality Is A Belief

• We are either being pulled by the system away
  from our beliefs in favor of its interests
• or
• We are guiding our system to help us evolve under
  our beliefs

4
A Physicians Beliefs
For doctors it all starts in the third year of
medical school
5
Its All About Diversity and Beliefs

• Medicine
• Nursing
• Pharmacy
• Allied Health
• Hospital Administration

• Public Health
• Dentistry

6
Practitioners for
2005 Must
Pew Health Professions Commission

• Participate in Coordinated Care

• Accommodate Expanded Accountability

• Involve Patients and Families in Decision-Making

• Continue to Learn

7
The Internet is an Alternative to the Doctors
Opinion
8
Patient Safety Goes Public in 1995

• AMA tort reform positioned to pass
• Willie King Florida,wrong side foot amputation
  in Diabetic patient
• Betsy Lehmann Boston, over dose of chemo-therapy
  kills Boston Globe reporter
• Ben Kolb Florida, topical epinephrine given IV
  kills child during minor ear surgery
• Tort reform fails, 1996 first Annenberg
  conference on patient Safety is held

9
Errors Become Big News
10
Senate Subcommittee - Is It A
Crime?
(Sen. Arlen) Specter, Chairman of the Senate
Appropriation HHS subcommittee, has voiced some
support for mandatory reporting of medical
errors, saying that colleges did more to fight
crime on campus once they had to report crime
statistics.
Taken from Modern Healthcare. Jan 31, 2000
11
From Crime to Patient Safety for Adverse
Drug Events

• Texas jury blames bad penmanship for patient
  death physician pays 225,000 fine.
• Nurses charged with manslaughter in case with 59
  errors prior to the accidental IV administration
  of IM penicillin when the antibiotic was not even
  indicated
• Acquittal marks the beginning of the patient
  safety non-punitive environment effort
• Star witness is Mike Cohen, President, ISMP

12
Central Truths of Improvement

• Every system is perfectly designed to get the
  results it gets
• Every change has both a technical and a social
  aspect
• Technically rational changes can fail if the
  social aspects of change are not handled well

13
The Non-Punitive Culture
Focus is on best results and high human
satisfaction
High
High
Cooperation
Driven
I value meeting
I value getting
Control
peoples needs
Compromise
results
Driven
(Service)
(Production)
Driven
Avoidance
Driven
Low
Low
14
Getting Self Awareness
15
Blaming Cultures are Exclusive

• Those blaming believe they are different from
  those that make errors
• Mistakes are unacceptable and show incompetence,
  lack of attention
• These professionals also expect to be blamed,
  Unfairly
• They often resist any negative feedback
• They do not get involved in system changes

16
Non-Punitive Cultures are Inclusive

• We all have beliefs and attitudes which
  preferentially include or exclude others in
  subtle ways.
• If we are not instituting practices, policies,
  and behaviors to counter the exclusion, then we
  support it. There is no neutral ground.
• The process of creating change begins with
  personal transformation, and then extends to
  facilitating others in a similar process

Courtesy of Innovations International Inc.
17
Exercise What Do You Believe?

• Reflect on your belief about the differences
  between physicians, nurses, pharmacists, allied
  healthcare providers, managers, administrators.
• List one belief held by members of one of these
  groups that is most likely to keep them from
  participating in non-punitive feedback.
• Give an example of a behavior that you have seen
  that is the result of this belief or attitude.
  Share this example and the belief that caused it
  with your neighbor.

18
The Offender and the Offended Share The Same
Belief

• What are your buttons?
• How do you transcend your beliefs?
• The process of creating change begins with us.

Courtesy of Innovations International Inc.
19
Finding Clarity

• Clarity is the correspondence between what is
  understood and what is actually observed

Institute for Strategic Clarity

• We are observing the same event, but we only
  understand what we believe to be true

20
The Party Is Interrupted

• Robert believed the party was over and that his
  watch had probably stopped...
• Cindy believed the host had gone into labor as
  she was pregnant and Cindy is an OB/GYN
• Jack believed his under age friend had gotten
  caught with a glass of spiked punch, as he slowly
  set his glass down

21
Internal External
Science, Ordered and Known Finding
Leadership Awareness and Reflection
Singular
Systems, Complex Interactions Connections
Non-Punitive Evaluation with Others
Plural
22
Understanding Levels of Development
Leaders Understand
Evidence Standards
High
Mid
Low
Non-Punitive Culture of Communication
Systems in Place
23
Raising Your IQ
Leaders Understand
Evidence Standards
Culture Communication
Systems in Place
24
We Need a Healthier Community of Quality

• Groups begin to create knowledge about each other
  through Dialogue
• Leaders emerge to tell their story and their
  assets become clearer
• They begin to recognize and respect the need for
  Diversity in the system
• Then they can begin to truly know the facts about
  each other

25
My Understanding Becomes Clearer

• Suddenly assets across a boundary are recognized
  and problems thought to be unsolvable by one
  group become visible needs of both groups
• Groups cross the traditional boundaries forming
  partnerships to shape the future
• They set and support each others priorities

26
Tossing a Bird?
Attractor - Push vs Pull
Tossing a Rock?
y x2 b
?
f ma
27
The Agile Competition for IQ

• It is a game that never ends
• It requires clear actions and rules
• It uses a common language and common goals
• It has structure standards
• It has winners, they score more points
• Intrinsic and extrinsic rewards are attractors

28
Raising IQ is about Communication

• View IQ as a Serious Cooperative Competition of
  Invention and Communication that never ends
• Build support for milestone completion
• Help people achieve accountable actions on a
  timeline
• Evaluate progress toward expectations as
  opportunity achieved

29
Conflicts of Commitment

• A commitment to one game may risk a loss in one
  of the other games
• Life and death
• Eminent Injury
• Likelihood that something bad will happen
• Possibility that something unintended and
  negative could occur across a boundary

30
Systems Influencing Other Patterns
Creates Leaders
Creates New Facts
The Inter-relating Safety Network
Creates Deeper Beliefs as Groups Agree
31
Data Influencing the Other Patterns
Must be Used as Language by Individuals
Required Standards
Fit in Cause and Effect Systems
Used in Non-Punitive Evaluations and Agreement
32
Culture Responding to Other Patterns
Listening to Someone Else
Getting the Facts
Diverse Understanding of Complex Results
Non-Punitive Culture of Communication
33
Individuals Responding to Patterns
Ongoing Reflection and Awareness
Learn the Language, Recognize Evidence
Individual Understanding of Complex Results
Participate in Non-Punitive Evaluations
34
Leading And Living ChangeYou must be the
change you are attempting to create.Mohan
das Gandhi1869-1948
35
Non-Punitive Cross-Cultural Communication

• Communication is grounded in intent and intent is
  heavily influenced by culture
• Cross-Cultural Communication requires knowing
  what you intend and learning to listen to the
  intentions of others

36
Communication Intent What Is Said, What Is
Heard
Sender
Message
Receiver
Intent Language
Interpretation
37
Mastering Cultural Communication

• Exercise Overcoming Judgment
• I am going to talk to --------, what do I expect?
  What am I thinking about her? What is her
  culture? How will I recognize her intent? What
  will it look and sound like? What is my intent
  for this conversation? What key words convey that
  intent and can be heard in her language?
• I am now ready to communicate.

Modified from Linda Galindo
38
Mastering Cultural Communication

• If I did this before every interaction, what
  would the outcome be?

39
Raising the IQ Game of Continuous
Communication and Invention

• Knowing the Players (IQ learning group)
• Knowing the boundaries to cross with cooperation
• Setting milestones to reach learning goals
• Scoring points (the measures)
• Starting the next game

40
Saving Lives When the Rules Collide

• Pregnancy in the ICU Story