The evening before Valentine’s Day, my son, Brad, and his wife, Maureen, went out for a nice dinner at a small bistro in Coronado, California, which is a beautiful resort town near their home. As they were looking over the menu, Brad noticed flames suddenly flickering over the top of his menu. He put down his menu and looked across the table at Maureen, who was studying the bottom of her menu so carefully, she didn’t notice the top was dangling above the candle on the table and had caught on fire.
“Maureen, your menu!” Brad alerted her. She looked up, screamed and dropped her menu on the table, which then caught the table cloth on fire. The couples at nearby tables immediately grabbed their glasses of water to toss on the fire and extinguish the flames. Needless to say, I’m sure this was a Valentine’s Day Brad and Maureen will never forget!
Aside from sounding like a scene from a romantic comedy, this scenario made me think about how sometimes, we become so focused on something we are doing that we miss detecting something that’s rather obvious or unexpected (like your menu being on fire). Or, at other times, we can become so distracted by a single task or detail, we fail to look at the situation as a whole.
When it comes to being focused on a task, we commonly mean thinking about one thing while filtering out distractions. So, it makes sense that if you give your full attention to one task at a time rather than trying to do several things at once, you’ll have higher quality results. But in reality, we have all learned to function well while multitasking. In fact, we can even become overwhelmed at times by information, a load of projects, or technology to be used. Trying to focus on too many things at once can easily open the door to mistakes. As the Nobel Prize-winning economist Herbert Simon wrote, “Information consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention.”
There are a couple of big ways not being focused, whether on our environment or on a task at hand, can have an impact—like on Best Care, for example.
Here’s a possible scenario. Two boxes of medications are packaged very similarly. While trying to perform more than one task, like answering the phone, I might accidentally grab the wrong box, expecting that I have the correct one. After all, it’s a medicine I administer almost every day! That could be a costly mistake for my patient! Fortunately, we have a bar code medication administration system which, when used properly, can catch my error.
Here’s another example. I am having a pretty good day, but very busy. I am walking down the main corridor of Jennie Sealy Hospital and checking an email on my phone. While I am trying to also watch where I walk, I fail to notice the expression on the face of a distraught family member who is trying to find the intensive care unit to visit their loved one. Or, I may even simply pass someone who is lost and trying to get to their clinic appointment on time. Let’s put down our phones and focus on our surroundings when we are traveling throughout our campuses and health system complex. No matter what our role, we all have a job to do in assisting visitors and patients who may be lost or confused trying to navigate our large system of facilities. Some of you have asked me how you can help achieve Best Care. This is one way you can do that.
To err is human—we all are capable of missing details. That’s why realizing we are susceptible to filtering out incoming information in our environment is important. Because we work in a fast-paced, demanding environment, we must practice awareness and remain vigilant about the safety and quality of the care and service we deliver.
Here’s another perspective on our Best Care focus. There are different ways of thinking about Best Care—there are the simple things we can all do each and every day that contribute to a positive patient experience, some examples of which I described above. But there is also the technical side of the coin, where we are collecting different forms of data to understand and track our performance in delivering care. We collect information on the cost of care, and we also use clinical documentation to reflect how ill our patients were and to record the processes of care we used to treat them. Together, this information determines our ranking for certain quality measures, like mortality or efficiency. So, it is possible to be so focused on moving the needle—improving Best Care—that we could lose sight of the fact that the ultimate goal of it all is to always do the right thing for our patients. Best Care means we are honoring patient-centeredness and delivering on outcomes that matter to patients and their loved ones!
In closing, I’d like to share a short video. Please watch it and follow these instructions: In the video, there are two teams of three persons each, one dressed in black and the other in white, revolved around each other and passed basketballs to their teammates. Count the number of times the ball is passed among the players in white.
This was a study conducted in 1999 by psychologists Daniel Simons and Christopher Chabris. They discovered that consistently, about 50% of their study participants failed to notice the gorilla. Whether or not the individuals saw the gorilla was not an individual difference trait. And interestingly, those who did see the gorilla could not believe that others actually failed to see it!
It just goes to show the importance of “avoiding distractions, paying attention to what others might notice, remembering that looking is not the same as seeing, and realizing just because your eyes are open, it doesn’t mean you’re seeing something!”*
*Mike Lyles, Quality Engineering Program Manager