Safety Nurse says, "Tweet this!"

If you have a professional or personal passion and haven't yet been to Twitter, the mothership of micro-blogging, you should! In the twitterverse, I am Safety Nurse. (Be patient, the taxonomy will chafe less with time.)

Why Safety Nurse?
I'd like to think that when I seek health care, I don't come out with more problems than I had when I went in. And I want the same for you. That makes me a patient safety advocate.

Here's why I find Twitter useful:
Twitter makes it easy to find others who have the same or parallel interests. I share resources and ideas I find worthy and evaluate what catches the attention of others. Filters and selective decisions about who I "follow" enable me to see tweets that are more likely to yield high-interest information, leaving minutiae tweets in the background. (There is something of an art to figuring out how not to see game results from someone's little leaguer. Again, filters are our friends.)

Twitter is a powerful virtual community, bringing people (and their opinions, insight, and networks) together with efficiencies not previously possible.

What can be said in 140 characters:
The 140 character limit can be a challenge, but often ignites creativity. Links to other sites are frequently included in the 140 characters, but the length constraint is actually desirable. Tweets exceeding 140 characters are the equivalent of "get a room" (or "get a blog").

This is what I tweet:
In 2001, the Institute of Medicine published a seminal report, Crossing the Quality Chasm, that identified six healthcare characteristics that lead to better, cheaper, and more reliable systems. They are:

• safe
• effective
• timely
• efficient
• patient-centered
• equitable

The IOM's "Big 6" continue to form the backbone of reform measures that stakeholders champion (or resist), and that citizens hear batted around as healthcare reform takes center stage. Although I'm primarily interested in processes that make healthcare safer, I promote and pass-along sensible ideas that address or help align the other five.

Outlier tweets:
Occasionally I tweet something only tangentially related to heathcare, like: Beer is proof that God loves us and wants us to be happy. -Ben Franklin. I also choose to follow a small number of folks who tweet outside of my primary areas of interest. For example, I follow Coldplay, an activity that leads me to free downloads when the band decides to reward their followers. (Whether Twitter leads you to freebies depends on your area of interest. I'm a medication safety advocate, meaning you shouldn't count on finding directions to a valium salt lick anytime soon.) I also follow Marlee Matlin because she's a high profile deaf person who tweets helpful things about captioning and deaf advocacy that I like to know about.

Tweet at ya later!

Who are these people? And why are they here?

There's a story in my family that starts with some elderly relatives being brought to the wedding of their grand-daughter. Maybe her second wedding, maybe her third. In any event, the grandmother was having a tough time putting the pieces together. Whether that had to do with organic brain dysfunction or simple human error in cateloguing multiple unions of multiple grandchildren isn't clear.

As the bride marched upon the altar, the grandmother was heard to say quite loudly, "Who are these people? And why are they here?" This question has remained active in my family, where we use it to qualify credentials or mission objectives when something doesn't seem quite right.

You can find some answers to this question, this time asked about me as part of Medscape's "meet the hosts of Grand Rounds" series. Here's the link: http://www.medscape.com/viewarticle/704561.

If you're not already a Medscape user, you'll need to register to access the article. But do take the time to do it. Medscape is a great platform for continuing education, blogs, and up-to-date news from the health care front. (You'll find Flo's sister blog, "On Your Meds" over there, too.)

Grand Rounds: Leveling the Field

Welcome to Grand Rounds! It's officially summertime, and Flo & Bo are taking you out to the ballgame! At Florence dot com, Bo, a seasoned nurse with an engineer's mind, channels Florence Nightingale, a systems thinker whose interest in public health and service gave rise to modern nursing. (Flo favors cricket, but this is Bo's gig.)

We make commentary about health, health care, and healing, a pursuit that, like baseball, often reveals motivated players, talented coaches, amazing facilities, and enthusiastic fans. But the game we follow is highly variable and outcomes don't always match the raw potential of the franchise. Maybe you have a team like this in your town?

Grand Rounds gave us an opportunity to ask people who blog about health care, "What's meaningful to you?" We were particularly interested in how IT solutions should be put to work to improve population health, individual health, and system efficiency.

We've appointed one of the USA's premier health care quality experts, Don Berwick, to be our honorary commissioner and have seated this week's submissions according to Berwick's four levels of interest. You'll find the experience of patients and families in the A position. The people and processes touching them are at Level B. Organizations where care is delivered are Level C, and other stakeholders and interests make noise from Level D.

The game is made all the more interesting because this group rarely stays in their assigned seats: players talk strategy; owners become players; players become owners; and fans have multiple allegiances. Got it? Good.

Now, let's play ball!

Throwing out the first pitch is e-Patient Dave who provides a compelling description of Meaningful Use: A pivotal definition of new-wave medical records systems. (Dave's vision may render advice for dealing with computer-related aches and pains obsolete, but if you need some while awaiting the "meaningful use" revolution, you can find it at Are Computers a Pain in the Neck (and Head)?)

Level A: The Players' Line-up

Laurie Edwards leads off with a hit Talking Health Reform with President Clinton. Edwards is a veteran patient-blogger determined to see patients' perspectives included in healthcare reform in a meaningful way.

Next up, Novel Patient shares how weighing the risks and benefits of potentially dangerous medication is a high-stakes wager for many patients in The Rituxan Gamble. It's early in the game, and we're reminded that, for many people, access to cutting-edge treatment is a hard-fought opportunity to bat, not the assurance of a run.

Batting 3rd is Amy Tenderich from DiabetesMine, the switch-hitter patient-entrepreneur, sharing submissions from this year's $10,000 DiabetesMine Design Challenge in Even More Bright Diabetes Ideas: A Little Help from Your Friends. Tenderich widens the players' circle, noting that her innovators frequently utilized patients' family and friends, valuable resources that have remained largely untapped in chronic disease management.

And in the power hitting position comes Duncan Cross, with a new blog round-up publishing patient-centered posts in Patients for a Moment: First-Ever Edition.

Next at bat:

Barbara Kivowitz takes a swing at discriminatory laws in Kept From a Dying Partner's bedside. What gets family into the game anyway?

Alison demos how new technology has made substantial improvements in her ability to manage diabetes, a claim she backs up with impressive data in her post Every picture tells a story.

Gold Glove Award Winners:

Dale Ann Micalizzi, a national champion for transparency and disclosure in the aftermath of her son's death, offers "The Power of Apology" by Dr. Marie Bismark." Dale writes, "After 8 years of searching for peace and answers, we received an apology last week from the physician who was an expert for the hospital and reviewed Justin's chart. The apology mattered and was appreciated beyond words even though it took so long."

Player/manager, WellRoundedType2 translates Changes in the way diabetes is diagnosed, for her team members, individuals she describes as interested in "Health at Every Size."

7th Inning Stretch:

Players' interests have been represented for a long time, and Disruptive Women in Healthcare introduces the May Man of the Month -- Charlie Inlander, who shares his lifelong experience as a patient advocate.

Bottom of the 9th:

Pinch-hitting for safe medication use and people at-risk for adverse drug events is Mona Johnson, with Anticholinergic medicines and memory loss.

Dean Moyer, someone with first-hand knowledge of back pain, offers a low tech method to obtain meaningful relief of neck pain in Neck Pain, Massage Therapy and Ice.

And Kerri Sparling, wearing number 6 (or Six Until Me), makes a fast call on a play, balancing the need for privacy with the urge to network in Do I Have the Right?

Level B: The trainers, managers, and coaches

Honorary team physician Daryl A. Rosenbaum MD wants players (and their parents!) to understand the limitations--and possible hazards--of mass production sports physicals in 10 Reasons Why Sports Physicals Need an Appointment.

Reality Rounds analyzes a case involving incarceration of an HIV+ pregnant patient in Get Ye to the Stockade, Ye Pregnant, HIV+ Wench! Knowledge of infectious disease, public policy, law, and a big dose of advocacy. If it's not an agent, it must be a nurse!

Catcher turned coach Amy Romano, MSN, CNM shares what happens when consumers and providers pursue evidence-based answers in "Flip Flop: How we (or at least Canada) went to routine cesarean for breech and back again in the era of evidence-based medicine."

Captain Atopic, a seasoned professional in the midst of changing roles in healthcare, reflects on his evolving perspective in Not My First Surgery. Flo & Bo appreciate the Captain's nod to how others see the game. Baseball culture, healthcare culture, it's all about culture.

Teen Health expert Nancy L. Brown, PhD shares survey results about teens' perceptions and offers advice for Giving Teens Purpose and Hope for the Future. (Bo, remembering teen behavior from her days as a perinatal nurse, is trying to figure out which base to have Dr. Brown coach. While this issue is taken to various stakeholder groups, go ahead and pass the link to Teen Health 411 along.)

Thrown out of the game?

The Jobbing Doctor reports the anonymity of bloggers is under threat in the UK by a combination of the London Times and a maverick judge in Who is the mystery man?

Back in the US, Evan Falchuk, writing for Team See First, advocates for accurate diagnosis of what ails health care as a necessary step for effecting meaningful reform in Some of My Best Friends are Doctors.

A Mom and Apple Pie Issue?

Dr. Linda Brodsky calls for stories related to gender inequality in health care for a multi-author book project in Hear Ye, Hear Ye!. Brodsky, another seasoned vet, puts questions of gender inequality and its impact on the quality of health care in the US in play.

Level C: The Organizations

CEO Paul Levy is Running a Hospital, a highly transparent one in Red Sox territory, where his blog is used for daily communication, shaping culture, opinions, and policy along the way. In Caller-Outer of the Month Award #6, he shares how the wisdom of frontline clinicians is utilized and recognized.

Rita Schwab effectively explains why the game should be understood by all people at all levels. Read past the opening nod to Health Care Risk Management Week and find a useful scorecard to help you determine if "patient safety" is a wild pitch or an intentional walk in the organizations you frequent.

The fitness of any organization is influenced by its infrastructure. Joseph Kim, MD, MPH shares findings from a research study, examining How many nursing homes use Electronic Health Records (EHRs)?

Level D: The Fans (and other interests that shape how the game is played)

Ever get to your seat at the ballpark and discover you (or someone in your party) has apparently offended the Ticketmaster God? Healthcare's another arena where people from very different places come to watch--and try to influence--how the game is played.

DrRich, a versatile manager-turner-agent, now with The Covert Rationing Blog, illustrates how mature medical technology (unlike mature consumer technology) often remains excessively expensive in Why Implantable Defibrillators Are Still So Expensive.

In The Economics of Health Care, Bob Vineyard of InsureBlog explores health care economics, advocating that reform measures include greater personal responsibility.

Louise and Jay, health insurance professionals, take a turn as players this inning, sharing what they know about Removing an Exclusion Rider on Our Policy in hopes of helping others. Alvaro Fernandez, of SharpBrains fame, is in the stands Debunking 10 Brain Training/Cognitive Health Myths.

Finally, The Cockroach Catcher's Dr Am Ang Zhang writes up Winter’s Tale: Blood, Entrails & Hansard and finds the collapsing of parliamentary record in a Shakespearean comedy to be a strong metaphor in the United Kingdom. (Bo sees the Curse of the Bambino being somewhat analogous on this side of the pond, although perhaps not a tale that portends health care woes in quite the same way.)

Thanks for coming, folks! This one's in the books. Next week, Grand Rounds is hosted at Edwin Leape.

Special thanks to my son, Luke Dixon, a real-time sports oracle and blogger at PucksNStuff, for providing enough baseball factoids to get this game played!

Meaningful Use: Your prescription shouldn't have to look like this

I spent a year studying medication safety at the Institute for Safe Medication Practices, the nation's only patient safety organization devoted solely to medication error prevention and safe medication use. So I'm always on the lookout for ways to help others see what I learned to see.

My friend had a friend-of-a-friend deliver a load of pine straw to her home the other day. The delivery man left an invoice, and my friend asked me to interpret the name of the company so that she could write a check.


Take a look and see what you think.

I guessed "Chevrolet" (even though it seemed like a weird name for a handyman service.) My friend frowned. She's a middle-school math teacher, and she's detailed-oriented. "Leave it blank," I suggested, "and mail it. Mr. Pinestraw can fill it in." More frowning. (This suggestion was clearly not welcomed by my friend, one of the most reliable people I know, someone who dots her i's and crosses her t's and is not in the habit of leaving things blank.)

Several days later, my friend mentions she's going to drop the check for Mr. Pinestraw off, having finally tracked him down via telephone and clarified the name. "Cherokee!" she says triumphantly!

To average Walmart shoppers like myself, health policy and IT discussions about how $20 billion dollars in economic stimulus funds are going to be put to meaningful use sound a lot like Charlie Brown's teacher: "Waoao waoaoa waoaoa wah woaoao."

So, let me draw on the med safety expertise and call out a few suggestions for how I think monies spent for meaningful health IT should be visible to healthcare consumers:

1. People who prescribe medications should use a system more sophisticated than the pine straw delivery guy's to communicate high-stakes drug information. 1,400 commonly prescribed drugs have names that look-alike or sound-alike. People can, and do, die when drug names are confused with one another.

2. Pharmacies should be able to receive prescription data in a format that does not require the tenacity of a middle-school math teacher on summer holiday to decipher.

3. Your electronic medication history--housed with your physicians, pharmacy, and any consumer portal you choose--should move seamlessly into hospital data repositories and be accessible, with your consent, during planned and emergent encounters.

Meaningful Use: What Flo Knows

The term "meaningful use" describes the way health information technology should be put to work to improve population health, individual health, and system efficiency. Stakeholders have been aTwitter (search #MU) because IT applications/solutions that meet "meaningful use" criteria will be able to snag a piece of the $20 billion ARRA monies.

If you're new to how the delivery of health care impacts outcomes, you can join those of us who have been screaming and clawing our faces for some time by perusing these dismal stats:

• 2009 estimates of infant mortality rates (considered a reliable indicator of the level of health in a country) show the US at 6.26/1,000, behind Sweden's 2.75/1,000, Germany's 3.99/1,000, and the U.K.'s 4.85/1,000. (We're 2 notches up from Croatia, which posts 6.32/1,000)


• For every $1 spent on health in the US, our G-5 competitors spend $0.63

Meaningful use should not define health IT. It should define what health IT enables: meaningful use of information technology to achieve desirable outcomes. This is what IT has done for every other sector of the economy, including the Amish micro-economy, in which people--who are as-off-the-grid as you can get--manage their agriculture and cabinet-making businesses (albeit with generator-powered computers).

If the Amish comparison is too far out for you, here's what Ivan Seidenberg, Chairman and CEO of Verizon Communication, said in the The Business Roundtable Health Care Value Comparability Study, published earlier this year:

"When it comes to scientific advances, medical technology and the quality of our doctors and hospitals, the American system is robust. But health care is beyond the reach of an increasing number of Americans. From our perspective, the problem with the U.S. health care market is that it doesn’t really function as a market – it leaves major consumer needs unmet, costs unchecked by competition and basic practices untouched by the productivity revolution that has transformed every other sector of the economy." (emphasis mine)

I've got to believe that the productivity deficit Seidenberg calls out has something to do with how IT works (or doesn't) to achieve operational efficiencies. IT doesn't move us toward a healthcare whole although it's certainly been harnessed to great benefit for individuals lucky enough to be able to access high-end care (just ask me or any other parent who talks to their cochlear-implanted kids on a cellphone).

When patients seek care or healthcare workers go to work, IT doesn't show up in the ways we've become accustomed to. Oh, it works in the piecemeal, "best of breed" way that we've asked it to, supporting the piecemeal "best of breed" health system we've concocted. But IT, as currently designed and implemented, is wholly insufficient for the complex tasks-at-hand.

Yesterday, a preliminary report from the Health IT Meaningful Use Workgroup was made public. Not everyone is happy. And there may be opportunity to improve on the first stab. But so far, I've found the preliminary Meaningful Use materials to be true to the IOM's Six Dimensions of Care, elements seen as the backbone of a healthy health care system.

Safe, effective, timely, efficient, patient-centered, and equitable. The Big 6, first defined in Crossing the Quality Chasm, the road map to healthcare improvement we've been asked to follow for the past 8 years. Only now, we may have meaningful IT vehicles to help take us there.

Grand Rounds: Searching for meaning

Flo & Bo are pleased to be hosting Grand Rounds, the weekly carnival showcasing the best of the medical blogosphere, on June 23rd.

Since healthcare is abuzz with talk about "meaningful use" this week, send us something you think is meaningful, and we'll fit the pieces together.

Submissions welcomed until 10 pm (EDT) on Sunday, June 21. Send to: blynnolson at gmail dot com & include "Grand Rounds" in the subject line. (This will help me differentiate what's meaningful to you from what's meaningful to the people who seem to think I've won the lottery when I peruse the Spam file.)

Here's the e-prescription:

• name of blog
• URL of blog
• title of post
• URL of post
• blog (or post) author
• twitter URL (if you tweet)
• brief description of what makes your post or perspective meaningful

See you next week!

Change of Shift: A Virtual Care Plan for Effective Communication

Welcome to Change of Shift, nursing's vibrant blog carnival! I'm thrilled to be your guest host this week and hope you'll find the posts embedded here as interesting as I have. If you're visiting my blog for the first time, I should warn you that I channel Florence Nightingale. I don't take extreme liberties with Miss Nightingale, just try and figure out what her work might say about ours. Sometimes I hit, sometimes I miss. Today, I'm weaving the voices of front line clinicians, consumers, and other interested (and interesting) bloggers around the theme of communication, showing, perhaps, where we are ("Can you hear me? Can you hear me now?") and what enhanced communication might do for us in the future.

Here's a story about engaging patients in their plan of care. It happened to me several years ago when I sought care in my local ED for unrelenting chest pain of 3 days duration, was diagnosed with bilateral pulmonary emboli and admitted for 5 days of inpatient anticoagulation. (This account, by the way, does not constitute medical advice from either Flo or Bo.)

In the early days, mostly spent waiting for a therapeutic INR to bubble up in my errant body-turned-chemistry set, I noticed a large whiteboard opposite my bed. The labels affixed to the board led me to believe that the date, weather, names of the people caring for me, plus key elements of my plan of care, could be written there. My boredom, spirits, and activity level increased in a linear fashion, and by day 3, I couldn't resist messing with the whiteboard which had remained uncluttered by any data save the preprinted labels. So I documented, as best I understood it, my plan of care: vegetate; oxygenate; medicate; anticoagulate; educate; ruminate; irritate; agitate; & dissipate.

Since that appeared to be an effective way to engage others (it certainly seemed to hasten my discharge), I thought I'd categorize words of wisdom from the blogosphere in a similar fashion.

If you haven't met e-Patient Dave, I'm happy to introduce you to this remarkable gentleman. Dave blogs about his personal journey surviving kidney cancer at The New Life of e-Patient Dave and e-patients.net. An IT professional, Dave recently attempted to interface his complicated medical history, housed in a patient-accessible hospital e-record, with Google Health. The outcome? A personal health record riddled with serious and significant errors. Dave's experience is being used to illustrate the primitive state of electronic medical records, even when high-end institutional and consumer products are used by an IT professional. You can read about his testimony at the National e-Health board meeting here. (Be sure to click on the slide show for a quick re-cap of Dave's compelling story.) Since I believe consumers and front line clinicians share many of the problems that arise when IT solutions perform poorly, I thought I'd put "automate" at the top of the communication care plan. I'd also like to acknowledge the efforts of Dave and others who share their personal journey in hopes of improving the system. So we could add "advocate" here, too.

I was happy to see a piece about proper use of pulse oximeters from AJN's Off the Charts blog. So, in a nod to the A-B-C's I decided to put "oxygenate" near the top of the plan of care. RehabRN's War Stories post talks about things that, while not oxygen, deserve top billing on a priorities list. (You'll have to take a deep breath while reading this one, another defense for indexing it here.)

See Jane Nurse adds "medicate" to the plan (or maybe she doesn't) in a post entitled No More Nitro for You. Ross, a Nurse in Australia, writes Medication Errors: Behind Closed Doors, putting the issue of medication errors on the chart (or, if you read what he correctly notes about under-reporting of errors and disclosure, maybe he doesn't).

If "medicate" hasn't yet made the care plan for improving communication, I'll add it myself. Really. I blog about medication safety on Medscape (at On Your Meds), where High-Alert Drugs: Eating the Elephant One Bite at a Time advises how to avoid mix-ups involving the most commonly confused drug name pair. (Spoiler alert: it's morphine and hydromorphone.)

Staying true to his "can do" approach, Sean Dent at My Strong Medicine puts his addition to the care plan to work, evaluating two new television shows about nurses: Nurse Jackie vs. HawthoRNe: The Battle of the TV Show Nurses Continues.

Sandy Summers at The Truth about Nursing also takes on Nurse Jackie in a detailed piece that includes a link to the first episode.

Shauna shares what it's been like to be handed a painful diagnosis, examining the best way to proceed when the words on the plan of care are unwelcome in The Six Words I Never Wanted to Speak.

And if you're looking for comprehensive ways to evaluate, check out 50 Fascinating Online Psychology Tests provided by The Forensic Scientist Blog. (Flo & Bo thinking, "TMI." But, hey, please yourself.)

While healthcare is full of interesting challenges, we're not short on thinkers contemplating solutions. Over at Digital Doorway, Keith, a seasoned blogger and mentor to many (including Flo & Bo), examines health coaching as a natural place for nurses to apply their knowledge and skills in Health Coaching and Multiple Chemical Sensitivity. Thanks for modeling out-of-the-box ways to nurse while dealing with personal health challenges. You get the first, but not only entry, under "Cognate," Keith!

Mother Jones at Nurse Ratched's Place considers the merits of microblogging and online networking in The Twitter People, while fessing up, Nurse Jackie-style, to a small addiction problem. (Okay, Twitter-addiction may not be in the same league as Nurse Jackie's problem.)

Kim at Emergiblog, the mothership of Change of Shift, offers words of wisdom in the "just think" department, too. She points to the value of civil discourse when communicating in the virtual realm. If you didn't know what, Jane, you ignorant $^&*! meant before now, you're in for a treat! Pick your words carefully when documenting on the care plan, too!

Finally, if you want a textbook approach for maximizing your cognitive abilities, check out The SharpBrains Guide to Brain Fitness.

Over at Nurse Connect, Nurse Kathy provides a spot-on list of things she thinks could transform nursing and asks, What's on your nurse's dream list?. Read it (especially if you need a laugh). I'll simply say I could have squeezed her into the care plan under "automate," "medicate," or "cognate." But since she's exceptionally creative, I'm going to give her a special place in the communication plan of care: innovate.

The systems we rely on (Paging, e-Patient Dave! Paging e-Patient Dave!) often don't set up healthcare workers to win. In My Garage, Your Checklists & Patient Safety, Joe Bormel at Healthcare Infomatics illustrates how other industries apply principles from human factors engineering to determine when and whether humans benefit from prompts. Flo & Bo are always interested in spreading the word about "the science behind the compliance" (e.g., Joint Commission standards).

I somehow felt "procreate" should fall near the bottom of the care plan. (And may your fingers turn black and rot off if you enter it on mine!) But the topic is surely on the minds of bloggers. As a long-time perinatal nurse, I'm always interested in these conversations. My engineer's mind simply cannot wrap itself around processes that yield such highly variable results as Cesarean birth rates (spanning from 20% to 40% in the course of my 25 year career). What's up with that?

Chris, from The Man-Nurse Diaries, sums up what's being said about home birth in the blogosphere with Home Birth Bonanza. And a host of communication-sensitive strategies for promoting healthy birth experiences can be found In A Maternity Care Utopia at Rebirth.

Over at Reality Rounds, we get to see how incomplete unit-to-unit communication impacts staff in The Pregnancy Secret (or as the author aptly observes, "how nurses get outed at work when they are pregnant").

Dave at The Back Pain Blog sends words of evidenced-based wisdom about Back Pain and Your Mattress setting the tone for "rejuvenate," a key component needed to communicate. Finally, Nurse Laura from Nurse Connect adds her prescriptive advice. You'll know exactly what should be next on your "to do" list once you've read Nurses: It's Time to Reorient Ourselves.

Thanks for visiting! Use the comment space to add to the virtual plan of care!

Change of Shift happens again on 6/25, hosted by RehabRN. Send submissions to hotelrehab@nyms.net.

Disruptive behavior: Why this dog don't hunt

A hound dog lays in the yard and an old man in overalls sits on the porch. "Excuse me, sir, but does your dog bite?" a jogger asks. The old man looks over his newspaper and replies, "Nope." As soon as the jogger enters the yard, the dog begins snarling and growling, and then attacks the jogger's legs. As the jogger flails around in the yard, he yells, "I thought you said your dog didn't bite!" The old man mutters, "Ain't my dog."

That's disruptive behavior.

Since January 1, 2009 , The Joint Commission has begun addressing hostile behaviors using two new performance expectations:

• The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors.


• Leaders create and implement a process for managing disruptive and inappropriate behaviors.

Disruptive behaviors include the easy-to-recognize ("you-better-duck") kinds as well as passive-aggressive varieties that tend to dog morale, undercutting intention and outcomes. A short, but salient, discussion of disruptive behaviors can be found in "Behaviors that undermine a culture of safety," a Joint Commission Sentinel Event Alert published last summer. The document (and reference list) is chock-full of negative organizational outcomes that can be predicted to arise from disruptive behavior. Irrespective of your stake in the healthcare system, you'll recognize them: medical error; patient dissatisfaction; diminished recruitment and retention; litigation; and increased costs. The document also acknowledges that disruptive behavior is endemic in healthcare settings.

The relationship between disruptive behaviors and highly reliable performance is interesting to me, as are most variables that inform patient safety. I think there are valid reasons, rooted in what's good, right, and just, for people to treat one another with civility and respect. But what "respect," "civility," and "disruptive" look like to large populations of diverse people is subject to cultural nuance, and has always struck me as being exceedingly difficult to operationalize. (I was once a participant in a focus group where someone defined a "nice family meal" as one in which no one stabbed another diner.)

So my engineer's mind wanted to know this about disruptive behavior: "Does managing it lead to better performance?"

Significant barriers prevent this question from being studied in a linear fashion, but work done in commercial aviation over the past 30 years suggests that it does. The analyses of a series of fatal airline crashes in the 1970's led aviation safety experts to understand that human error is causally linked to failures of interpersonal communications, decision making, and leadership. To manage risks associated with human performance, a series of high level communication-oriented behaviors and performance activities, termed Crew Resource Management (CRM), evolved.

Normalizing behaviors within crews has improved the safety of air travel. Malcolm Gladwell tells riveting stories about why and how CRM works in his book Outliers. And a classic scholarly (but easy-to-read) 1999 analysis The Evolution of Crew Resource Management by Helmreich, Merritt, and Wilheim says more and is available online.

Crew resource management is emerging in healthcare with early AHRQ-funded projects now reporting and organizational templates, like TeamSTEPPS now available. The Joint Commission's acknowledgement that disruptive behavior creates breakdowns in the teamwork necessary to deliver safe patient care is an important foundational step in nurturing cultures in which safety is paramount.

Taking on disruptive behavior as the "safety-negative" bully it is, codifies something healthcare providers intuitively know but may have forgotten: If you stab people at the dinner table, they're unlikely to leap to their feet, performing the Heimlich maneuver with efficiency and aplomb when you choke.

Change of Shift: Coming Soon

Flo & Bo will be guest-hosting Change of Shift, nursing's vibrant blog-fest, here on June 11. You can expect a salute to communication, what the voices of front line clinicians, consumers, and other interested (and interesting) people mean to healthcare and healing.


As a new blogger, I've benefited from what you share every day and from the variety of engaging ways seasoned bloggers spread the word! I'm looking forward to "showing your stuff" here next week.

All submissions are welcomed. Please include:

Name of blog
URL to blog
Name of post you're submitting
URL/Permalink to the post
Blogger and/or post author
Twitter link (if you want to include one)
A few words about what you're submitting

Send via the blog carnival portal or directly using blynnolson at gmail. I'll be happy to include all received through 6/10 at 5 pm.

The pay-off for investing in natives

The picture of the oak leaf hydrangeas, now in full bloom in my southern garden, says a lot about what you get when you invest in natives.

The thirsty, showy, flashy things I tote home from the sick-plant outlet I patronize can be counted on to demand time and tax my talent. But the natives pretty much do their thing, reliably and predictably. And they always "wow"!

I use Florence dot com, sometimes as a primer, sometimes as a bully pulpit, advancing the idea that front line healthcare providers are natives in the patient safety garden. We should pay them some attention, invest to give them what they need to get started, then be ready to get out of the way.

Most seasoned healthcare professionals grew up in traditions that emphasized the primacy of individual effort over collaborative processes, traditions that neglected science-based approaches for managing the systems that inform performance. (If we wouldn't expect a fight crew to get from New York to Denver by "heading west, young man" why does anyone tolerate a system that tells nurses to deliver medications without more procedural guidance than "follow the 5 Rights"?)

Building reliability into work processes comes more readily when professionals are schooled in human factors and applied cognitive science. Schooling is part of the reason other industries reap the wisdom of the front line in a way that healthcare, as a whole, isn't yet doing. The tradition of "counseling" the last person to touch a process-gone-wrong is hard to give up (apparently it's akin leaving your roots). And healthcare workers often don't recognize, or can't do anything about, the bad soil they're planted in.

So I was happy to receive a tweet yesterday that led me to a partnership between Auburn University and Baptist Health in Montgomery, AL. Synergistic Management and Resource Team (SMART) training will teach highly reliable communication strategies, like those used in the airline industry, to front line healthcare practitioners and students and promote the use of these modalities at the front lines of care. SMART Training combines the tactics of crew resource management, purpose-based decision making, evidence-based practice and simulation.

It's worth noting that the curriculum was developed using the expertise of Auburn's Aviation and Supply Chain Management faculty in collaboration with professionals from Baptist Health's Institute for Patient Safety and Simulation Training. Applying knowledge that comes from studying the root causes of communication snafus to develop strategies that prevent recurrence is more rewarding, but far more difficult, than focusing on "who-didn't-hear-what-right-this-time." Teaching the science behind measures that are often seen by front line clinicians as "compliance-driven" rather than "safety-essential" may help cultivate healthcare's holy grail, the culture of safety.

Turned out it was in the garden all along. Smart. Or is that SMART?