Only wet babies likes change…

Why is it so hard to drive disruptive behavior out of healthcare institutions? It's because organizations are like living, adaptive organisms; they resist change, but adapt even to the most dysfunctional circumstances, if necessary. You were born with two kidneys, but can do pretty well with just one. If the second kidney starts to crash your body will fight to the death to work around the problems with electrolytes, red blood cells, acidosis, etc. In fact if we took out your bad kidney and gave you a good one, your body's immune system would immediately go to work to attack it. Organizations like living, adaptive organisms resist change. The healthcare industry has adapted to a lot of very bad behavior for a long time. So long in fact that it feels normal, and regardless of how dysfunctional it is, changing it won’t be easy. Here is one humble theory on just one aspect of what is driving this…

Technology and increases in knowledge are forcing a shift from a centralized complexity management strategy to a distributed one; and like a healthy kidney transplanted into a dying patient, the organism is fighting this change as best as it can. Healthcare is complex by its very nature. Organizations generally manage complexity in one of two ways; they either centralize it in the hands of “an expert few” or distribute a little of it across the masses.

Consider the example of fly versus driving for a trip across the country. In the first case, you have a half-billion pound piece of steel flying at 500 MPH and trying to land on a 50 foot wide piece of pavement. Very complex, but none of the passengers need to worry because all of the complexity is centralized across just a few people; pilot, co-pilot and air traffic controller. In the latter case you have millions of vehicles on hundreds of thousands of miles of highways, rural roads and streets, running in every direction, in varying states of repair, across varying kinds of terrain, and in all sorts of weather. No person or super computer could manage this amount of complexity, nor is it necessary. Instead, small pieces of this complex challenge are distributed across the millions of drivers; each only needing to concern themselves with safely getting from point A to point B. This is centralized complexity versus distributed complexity.

So how does all of this tie in to doctors and change and wet babies?? Rapid advances in technology and huge increases in knowledge are making it impossible for one individual to cenrally manage the complexity of treating human disease. They are being forced to move from a centralized complexity management strategy to a distributed one. For some people it feels normal, some will like it, but many find it very distasteful. They endured years of sleepless servitude to attain their position, only to find that everything is changing. Operating in this new environment demands a new mindset and new skills. Greater collaboration, new routines for gathering, interpreting, and redistributing knowledge, and a good process for resolving conflicts when they arise, just to name a few.

So we have a shift in the way complexity is managed, but just to keep things interesting, we must also contend with the unique power structure of hospitals. Doctors who are essentially individual contributors and often not even employees, wield enormous power and are being forced to change. The power they hold makes their ability to resist change a key challenge to work with. This really is a huge change management issue, and fixing it will require a unified approach. More on that next time…

The Trouble with Training

Training efforts rarely produce the level of impact that anyone hoped for when the initiative began. It happens when great information is delivered in a memorable way. It happens when exercises are included to provide people with a chance to test drive their new skills. Training efforts too often fall prey to rapid decay; the initial burst of enthusiasm goes out with a whimper. Why is this, and how can we make certain that our efforts to address disruptive behavior are sustainable?

Heads + Hands = Half way there

Most training efforts attempt to engage people’s heads and their hands. They provide information, tools and knowledge to equip people to handle new tasks, challenges and opportunities. This is an important step, and those who are truly engaged people will often take these skills and run with them. However, experience tells us knowledge doesn’t always get translated into changed behavior. After all, I know an oncologist who smokes!

An important addition to knowledge transfer is providing participants with skill practices that allow people to test drive their new skills, and gain confidence in their ability to use them in the real world. This is why pilots spend many hours in a simulator or doctors spend so much time in the gross anatomy lab. Dissecting a cadaver provides med students an opportunity to build skills in an environment where failure is not catastrophic.

Taken together, training the head and hands provides people with the “can do,” but they don’t address the “want to” challenge. I know how to exercise, I have the skills to exercise, but if I don’t chose to utilize the skill and knowledge, they will not yield any fruit in my life. The key lies in engaging the head, the heart and the hands.

Heads + Hearts + Hands = Harvest

The key to attaining sustained behavioral change is to engage head, heart and hands. By heart I don’t just mean those warm fuzzy feelings you get after an inspirational talk. My experience with very busy, high ego people is that those kumbaya’esq, “why can’t we all just get along” speeches don’t go over well. By heart I mean that you have to create conviction about using those skills. Not just “interest in” or “support for” using those skills, but rather a heartfelt belief that compels people to behave differently.

Creating this kind of visceral response does not come easily, and it rarely comes by telling people that they should feel it. It comes most quickly and most powerfully when people have experiences that lead them to change from “the insight out.” That is what I have found to be so rewarding about leading our classes on disruptive behavior. I will share an illustration in our next installment.

What have you seen that works? Is your organization doing something very effective in this area? Please share it here.

Leading Change from the "Insight Out"

In the interest of complying with JCAHO’s mandate for training and support on disruptive behavior, some institutions have used short web-based training or quick lectures on what constitutes disruptive behavior. Certainly this is an important first step, perhaps even enough to “check off” JCAHO’s training requirement, but is that good enough? Results from our September reader’s poll would indicate that it is probably not. Just 5% of respondents indicated that they didn’t know what the standard was for determining disruptive behavior, and another 10% said they weren’t sure how to report it.

Still, education is important because it allows us to draw a line in the sand (see the September 24 blog post) and clear up any confusion caused by the fact that disruptive behavior has become an accepted aspect of working in healthcare (the survey found that 25% of respondents said disruptive behavior was a tolerated part of the landscape, and 60% said that past reports were not acted on).

It follows then that education is just the start. In fact if education was all it took to change behavior, smokers wouldn’t smoke, we would all get 8 hours of sleep each night, and stop to smell the roses each day. Besides, you don’t go to your doctor just to get a diagnosis; you go to get a cure. In addition to telling people that there is a problem, there needs to be a time of equipping to solve that problem. But change, particularly behavioral change in healthcare doesn’t come easy.

In 2003, Deone Zell from Cal State Northridge wrote an interesting article in the Journal of Applied Behavioral Science. In it, Zell likens change in hospitals and high educational institutions to Elisabeth Kubler-Ross’5 stages of death and dying (denial, anger, bargaining, depression and acceptance). Both have an unusual bureaucratic, and highly distributed power structures. Professors and doctors are essentially individual contributors, yet they hold a great deal of power because their work brings grant money to the university, or patient volume to the hospital. Thus, they have a disproportionate ability to influence how and when things change.

They key to accelerating your way through these five stages, is to lead change from the insight out. Dr Rosenstein and I have collaborated with Eagle's Flight’s enormously creative CEO to create some fascinating ways to do this. More to come on this topic in our next edition.

In the meantime, please share your comments and insights on disruptive behavior below. The more we understand the how’s and why, the more we can integrate those understandings into our solutions.

Zell, Deone, (March, 2003), Organizational change as a process of death, dying, and rebirth
The Journal of Applied Behavioral Science; pg. 73

Where to start, where to start…

There are no easy answers, and in fact there isn’t always a clear place to start. Dr Alan Rosenstein, the physician whose research served as the impetus for JCAHO’s new requirements on disruptive behavior, says that there are no silver bullets. A multi-pronged approach that addresses education and training, culture, leadership, reporting, and structure, as well as an effective intervention strategy are critical. In the next several articles, we will discuss these topics in more depth. Today we begin with education. (In the interest of brevity please consider my use of the word hospital as encompassing long term care facilities, ambulatory surgery centers, physician practices, etc.)

In my somewhat arbitrary view, the education part of the equation is focused on articulating just what disruptive behavior is, and how disruptive behavior affects patients, the staff, and the institution. The training part of the equation is about equipping people with more effective behaviors for dealing with potentially disruptive situations. First, we need to get beyond the Alcoholic Parent Syndrome.

The Alcoholic Parent Syndrome. For too long, disruptive behavior in healthcare has been subject to the proverbial “alcoholic parent syndrome.” We hoped that if we ignored the bad behavior, it would go away on its own. Others took the duck-and-cover-until-they-cool-off approach. Still others “tried harder to be better” so the alcoholic parent wouldn’t get angry. Such responses have several serious side affects.

First, failure to appropriately address disruptive incidents in the past has served as a tacit form of consent. Fit-throwing children that are never rebuked by their parents often grow up to be fit-throwing adults. Similarly, hospitals that don’t act on the charge nurse who constantly berates and demeans their direct reports should not be surprised when they develop what one nurse described as a “Darwinian culture” where only the strong survive.

To add insult to injury, people often see a clear double or triple standard in how the institution responds to disruptive behavior from different groups. When a hospital’s tolerance for bad physician behavior can be correlated with that physician’s admission volume and patient profitability, people will see and resent it. It follows then that one of the early steps on the road to eliminating disruptive behavior is to actually call a spade a spade.

This could take place in many forms, but should have several key ingredients including a clear behavioral definition of disruptive behavior, a discussion about how that definition links to the hospital’s code of conduct, a zero tolerance policy, and an explanation of the hospitals reporting and peer review process.

JCAHO and the AMA offer definitions (see the links on the right of this page) or you can make your own. They key is to articulate in clear behavioral terms the kinds of:

*Words - cussing, yelling, etc.
*Actions - inappropriate touching, throwing things, etc.
*In-actions - failing to return calls, “forgetting” to do things, etc.

that consitute disruptive behavior.

When you tie the definition to your code of conduct and a zero-tolerance policy, it creates the fresh opportunity to both renew commitment, and draw a line in the sand between what was, and what is no longer acceptable. Once you have defined disruptive behavior and reinforced your commitment with a zero-tolerance policy, you need to lay out the process for reporting and handling disruptive behavior incidents (much more about this topic later).

What are your thoughts on why we are still having this discussion? Shouldn’t civility in the workplace be the norm?

No easy answers

Like so many other aspects of the healthcare field, the issue of disruptive behavior has few easy answers.

The definition is somewhat subjective - While we can all label and punch in the nose as disruptive behavior, one person’s condescending and belittling remark is another person’s “constructive criticism.”

Knowledge about disruptive behavior rarely changes disruptive behavior - My guess is that most smokers are aware of the risks, but given the number of people that still smoke, it appears that knowledge about the risks of smoking hasn’t affected their behavior. I even know an oncologists that smokes; who’da thunk it!

The context is ripe for disruptive behavior - Fatigue, life or death situations, staffing shortages, failed equipment, emotional trauma, not to mention substance abuse and stress of every day life.

Policies against disruptive behavior are generally inadequate (if they do exist), and poorly enforced – Even if a policy makes me think twice, the threat of punishment doesn’t fix the root problem. A policy is like a latex glove, it only keeps bad stuff from passing, but it has no power to heal or improve.

So now what? If we can’t change the fact that people tend to get sick at very inconvenient times, and education and sanction don’t work, how can we get to the heart of the matter and affect real change? We will explore this issue and some real answers over the coming weeks.
What’s your story? What ideas do you have? How do we get to the heart of the matter? Thanks for contributing!