When you can’t see the forest for the trees…

Donna Sollenberger, EVP & CEO, UTMB Health SystemThe 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!”*

change-blindness-ii

*Mike Lyles, Quality Engineering Program Manager

Why tread water when you can float?

Donna Sollenberger, EVP & CEO, UTMB Health SystemAs you already know from some of my prior Friday Flash reports, my grandson, Jack, is a swimmer. However, he is also only 10 years old, so he can be somewhat forgetful or disorganized when it comes to swim practice.

I am not a swimmer, so I am always fascinated by what the swim team does at practice. I have learned from Jack that one of the techniques his coach uses to help the swimmers gain upper body strength is to hold a flotation device, called a pull buoy, between their legs while swimming. The buoy helps keep the swimmers’ legs stationary and afloat as they swim through the water. This is an extremely important part of training, because it helps the swimmer focus on their arm movements, which is particularly beneficial for a swimmer who does the butterfly and breast strokes, like Jack.

Two weekends ago, my daughter, Jack’s mother, and I were having dinner when she told me an amusing story. For about three practices in a row, Jack had forgotten his buoy. His coach was not happy when he arrived at the third practice without it. So, to make a point, the coach told Jack that if he forgot it again, she was going to tie his ankles together and make him do the exercise that way—it must have made a point, because he hasn’t forgotten his buoy since.

As I thought about the prospect of trying to swim with my ankles secured together without a buoy, I thought about how we sometimes make work harder for ourselves than it needs to be. There are times when we are confronted with challenges, but we don’t remember to use our “buoy” for support, be it our co-workers, technology or available equipment. For example, do we ask others for help when feel overwhelmed with too much work? I know it is sometimes hard to ask for help, yet it is sometimes the best thing we can do.

I had a chance to meet a nurse recently who has worked at UTMB for about five years. She came to UTMB from a competitor hospital up the freeway, so I asked her what attracted her to UTMB. She told me that she had worked here per diem while she was a full-time nurse at the other hospital, and she noticed in her shifts at UTMB that if she had two new patients to admit at once, the other nurses on the unit always checked with her to see if she needed help. She told me that never happened at her full-time job. So when there was a full time opening at UTMB, she decided to quit her job at the other hospital and work here. I asked her if she felt free to ask for help if she needed it, and she told me, “Absolutely.”

I admire this nurse. Instead of struggling under a spike in workload and trying to do the job alone, she asked for and accepted help. Just like my grandson, Jack, she had decided it was easier to accomplish her work with a buoy as her lifesaver rather than trying to do the job with her “ankles tied together.”

Here’s another example. Most of the time, we have technology available to help us do our work more precisely, but we opt to take a shortcut to save time and don’t use the technology that helps make our work easier or safer. Not too long ago, we implemented a bar code system to help make giving medication to our patients safer—the nurse scans the patient’s wrist band, and then scans the bar code on the medication packet. This technology is a “buoy” that helps assure that the nurse is giving the right medication to the right patient, at the correct dose at the right time. If any of these variables are not correct, the technology then alerts the nurse that if they continue, there could be an error. Using the system literally can be a lifesaver, because it reduces the likelihood of a medication error. Although this cannot eliminate medication errors entirely, nor can it replace the diligence and critical thinking of the nurse, it is safer way for UTMB to provide high quality care for our patients in environments that have frequent distractions and elevated levels of stress.

What buoys do you have in your job that make your work easier? Are you using all of the tools you have to assure you are being as effective in your job as possible? Do you offer help when you see others need it, too?

Health care is a fast-paced environment. Asking for help and using the tools designed to make our work more efficient and processes more reliable equates to safer patient care and a positive patient experience. And sometimes, we can really benefit from the skill and expertise of our teammates. Asking for help isn’t always easy. But, sometimes it’s downright essential!

Accept yourself, your strengths, your weaknesses, your truths, and know what tools you have to fulfill your purpose. –Steve Maraboli

Today, I will learn something new.

Donna Sollenberger, EVP & CEO, UTMB Health SystemI am left-handed—at pretty much everything. I write left-handed, and when I played softball, I pitched left-handed. The only thing I really can do with my right hand is iron, and that is because my right-handed mom always left the ironing board set up in the utility room the way she liked it, ready to turn on. (I was too lazy as a kid to unplug the iron, collapse the ironing board, turn it around and set it up again, so that is how I learned to iron.)

When I was in elementary school, we were taught to write in cursive. Our lessons began in fifth grade, and by sixth grade, we were to use cursive exclusively. I wrote as most left-handers do: my left hand bent at the wrist, pen on the paper, dragging my hand across the ink, often smudging it across the page. At least, that’s how I wrote until Miss Bell became my sixth-grade teacher…

I remember the first time we were practicing cursive in the classroom. Miss Bell walked toward my desk, watched me write and then said, “You will not pass handwriting in my class unless you learn to write so it appears you are right-handed.” She then proceeded to show me how to do that, which involved turning my paper the opposite way and then writing without bending my hand at the wrist. I was mortified as all of the kids in class watched me. I was struggling. It felt so foreign to try to write that way.

I spent the better part of three months working and working on doing something differently than I had learned to do it for an entire year. I have to admit, it was really challenging. However, once I got the hang of it, cursive writing became easier and easier. Over the years, I have had people tell me that my writing looks as if I am right-handed, and most people who have seen my handwriting are surprised that I am left-handed.

I recall this part of my life now because the other day, my husband took a note I had written down to the front desk at the condominium building where we live. He came back amused that the two ladies at the front desk had asked him if he wrote the note. He told them that he did not; his wife had written it. One of the ladies asked him if I had ever won any awards for hand-writing! Now, I was laughing!!

The memory of trying to change something I had done for months, which had now become habit, made me think of the changes we are having to make to achieve Best Care. At first, we heard the goal and thought it really wouldn’t be possible. However, we also know that failure is not an option. We even have the University of Texas System Chancellor urging us on, and most importantly, we have patients who depend on us to give them the Best Care, every encounter, every time. So, some of us have to change the way that we have approached patient care, sometimes for years.

But change we must. So we begin by trying a new approach, one that we believe will get us the results that we were not getting before. For example, the way physicians document in the medical record the care they have given to a patient and the way they describe the patient’s illness can be the difference between being rated as a very high-quality or lower-quality academic medical center. Many physicians are having to learn to document differently than they have for years. It is hard to make the change, yet it is necessary so that we are recognized appropriately for the work we are doing.

In other instances, people who were trained step-by-step on how to document in the Epic medical record (because following that particular process helps ensure we are adhering to the recommended processes of care and that we are capturing all of the information we need) are then sometimes told once they are on the unit, “Oh, there is a easier way. Just do it like this.” And before you know it, the trained behavior is left behind because “there is an easier way.” Unfortunately, the easy way may actually make things more complicated for others who have to use the record further down the line. We may make the change to make our own work easier, but as a consequence, we unintentionally make work harder for someone else.

Can you think of a time when someone changed how they did their work, and that made your job harder? That is why, as we change our system and learn new ways of doing things, we need to do our part according to the way the process was designed. If the process needs improvement, let’s work on that together. Changing just our part may actually make it unsafe for the patient somewhere else down the line.

So, just like I practiced and practiced my handwriting until what I was doing became a habit, we must practice the changes we need to make in order to help us achieve Best Care. Whether you work on the loading dock, run blood tests in the lab, or develop work-flows to be implemented in the electronic medical record, let’s all work together, make sure we understand our role in the process, understand why we do something the way we do, and how our work impacts others. It is then that we have the greatest opportunity to achieve Best Care.

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