Silence Kills…Silence Kills…Dialogue HealsDialogue Heals

Betsy Burtis, MEdBetsy Burtis, MEd

Impact of Impact of Communication Communication

• 1 in 20 patients receive the wrong 1 in 20 patients receive the wrong medicationmedication

• 3.5 million get an infection from someone 3.5 million get an infection from someone who didn’t wash hands or follow who didn’t wash hands or follow precautionsprecautions

• 60% of sentinel events60% of sentinel events

• Return to ICU or death during Return to ICU or death during hospitalizationhospitalization

– Changes from 16% to 5%Changes from 16% to 5%

JCAHO 2007 Patient JCAHO 2007 Patient Safety GoalsSafety Goals

• Goal 2: Improve the effectiveness of Goal 2: Improve the effectiveness of communication among caregivers:communication among caregivers:

– Verbal or telephone ordersVerbal or telephone orders

– Standardized list of unsafe Standardized list of unsafe abbreviationsabbreviations

– Timeliness of Critical Test ResultsTimeliness of Critical Test Results

– Safe HandoffsSafe Handoffs

Benefits of Effective Benefits of Effective CommunicationCommunication

• Consistent delivery of careConsistent delivery of care• Helps manage the complexity of Helps manage the complexity of

patient carepatient care• Staff safetyStaff safety• Learning from mistakes vs. Learning from mistakes vs.

punishment/blamepunishment/blame• More rewarding work environmentMore rewarding work environment• Helps attract and retain employeesHelps attract and retain employees

Safety Red FlagsSafety Red Flags• Things don’t feel rightThings don’t feel right• AmbiguityAmbiguity• Reduced or poor communicationReduced or poor communication• ConfusionConfusion• Trying something new under pressureTrying something new under pressure• Deviating from established normsDeviating from established norms• Verbal violenceVerbal violence• Task fixationTask fixation• BoredomBoredom• Being overworked & tiredBeing overworked & tired• Being rushedBeing rushed

The Silence Kills StudyThe Silence Kills Study

• Columbia Disaster – lack of communication a key Columbia Disaster – lack of communication a key contributorcontributor

• 2004 - Surveyed >1700 people (300 physicians 2004 - Surveyed >1700 people (300 physicians and 1400 clinical care staff)and 1400 clinical care staff)

• Key Findings:Key Findings:– > 50% had seen broken rules, mistakes, lack of support, > 50% had seen broken rules, mistakes, lack of support,

incompetence, poor teamwork, disrespect and incompetence, poor teamwork, disrespect and micromanagementmicromanagement

– >50% say the problems have been going on for > 1 year>50% say the problems have been going on for > 1 year– Fewer than 10% discussed their concerns with the Fewer than 10% discussed their concerns with the

personperson

Typical Case ExampleTypical Case Example

• A Group of nurses describe a peer as A Group of nurses describe a peer as careless and inattentive. Instead of careless and inattentive. Instead of confronting her, they double check her confronting her, they double check her work – sometimes running in to patient work – sometimes running in to patient rooms to retake a blood pressure or redo rooms to retake a blood pressure or redo a safety check. They’ve “worked a safety check. They’ve “worked around” this nurse’s weaknesses for around” this nurse’s weaknesses for over a year. The nurses resent her, but over a year. The nurses resent her, but never talk to her about their concerns. never talk to her about their concerns. Nor do any of the doctors who also avoid Nor do any of the doctors who also avoid and compensate for her.and compensate for her.

The 7 Most Crucial The 7 Most Crucial Healthcare ConcernsHealthcare Concerns

• Broken Rules:Broken Rules: hand washing, hand washing, abbreviations, identifiersabbreviations, identifiers– 62%62%

• Mistakes:Mistakes: trouble following directions, trouble following directions, poor clinical judgment, medication errorspoor clinical judgment, medication errors– 65%65%

• Lack of Support:Lack of Support: complain when asked complain when asked to help, impatient, refuse to answer to help, impatient, refuse to answer questionsquestions– 53-83%53-83%

The 7 Most Crucial The 7 Most Crucial Healthcare ConcernsHealthcare Concerns

• Incompetence:Incompetence: competency and skill level competency and skill level– 53% 53%

• Poor Teamwork:Poor Teamwork: form cliques, gossip, try to form cliques, gossip, try to look good at another’s expenselook good at another’s expense– 88% 88%

• Disrespect:Disrespect: condescending, insulting or rude condescending, insulting or rude– 77%77%

• Micromanagement:Micromanagement: abuse of authority, pull abuse of authority, pull rank, bully, threaten or force their point of rank, bully, threaten or force their point of viewview– 52%52%

Why don’t we share our Why don’t we share our concerns?concerns?

• Drawbacks of confronting:Drawbacks of confronting:

• Benefits of confronting:Benefits of confronting:

Crucial ConversationsCrucial Conversations

The Seven Steps to Mastering a The Seven Steps to Mastering a Crucial ConversationCrucial Conversation

• Start with HeartStart with Heart• Learn to LookLearn to Look• Make It SafeMake It Safe• Master My StoriesMaster My Stories• STATE My PathSTATE My Path• Explore Others’ PathsExplore Others’ Paths• Move to ActionMove to Action

Start with HeartStart with Heart

• Ask Yourself:Ask Yourself:– What do I really want for myself?What do I really want for myself?– What do I really want for others?What do I really want for others?– What do I really want for the What do I really want for the

relationship?relationship?– What don’t I want?What don’t I want?– How would I behave if I really How would I behave if I really

wanted these results?wanted these results?– Use “and” rather than “but”Use “and” rather than “but”

Learn to LookLearn to Look

• Learn to look at content and Learn to look at content and conditionsconditions– Watch for three different conditions:Watch for three different conditions:

•The moment the conversation turns crucialThe moment the conversation turns crucial•Signs that people don’t feel safeSigns that people don’t feel safe

– SilenceSilence•Masking, Avoiding, WithdrawingMasking, Avoiding, Withdrawing

– ViolenceViolence•Controlling, Labeling, AttackingControlling, Labeling, Attacking

•Your own Style Under StressYour own Style Under Stress

Make It SafeMake It Safe

• Two conditions of safety:Two conditions of safety:– Mutual Purpose – shared interestMutual Purpose – shared interest– Mutual RespectMutual Respect

• When safety is at risk:When safety is at risk:– ApologizeApologize– Contrast (a do/don’t statement)Contrast (a do/don’t statement)– Commit to Seek Mutual PurposeCommit to Seek Mutual Purpose– Recognize the Purpose behind the Strategy Recognize the Purpose behind the Strategy

(get at the “why”)(get at the “why”)– Invent a Mutual PurposeInvent a Mutual Purpose– Brainstorm New StrategiesBrainstorm New Strategies

Master My StoriesMaster My Stories

• Notice Your BehaviorNotice Your Behavior• Get in Touch with Your FeelingsGet in Touch with Your Feelings• Analyze Your StoriesAnalyze Your Stories• Get Back to the FactsGet Back to the Facts• Tell the Rest of the StoryTell the Rest of the Story

– Why would a reasonable, rational, and Why would a reasonable, rational, and decent person do what this person is decent person do what this person is doing?doing?

STATE My PathSTATE My Path

• SS Share your factsShare your facts• TT Tell your storyTell your story• AA Ask for others’ pathsAsk for others’ paths• TT Talk tentativelyTalk tentatively• EE Encourage testingEncourage testing

Explore Others’ PathsExplore Others’ Paths

• Start with an attitude of curiosity and Start with an attitude of curiosity and patience. How do you rate as a listener?patience. How do you rate as a listener?– AskAsk– MirrorMirror– ParaphraseParaphrase– PrimePrime

• When you begin to share your views:When you begin to share your views:– AgreeAgree– BuildBuild– CompareCompare

Move to ActionMove to Action

• Dialogue is not decision makingDialogue is not decision making• Decide how to decideDecide how to decide

– CommandCommand– ConsultConsult– VoteVote– ConsensusConsensus

• Determine who does what by whenDetermine who does what by when• Document Your WorkDocument Your Work

PreparationPreparation

• What’s the hardest thing you ever What’s the hardest thing you ever learned to do?learned to do?

PracticePractice

• In groupsIn groups– Crucial Conversation StarterCrucial Conversation Starter– ““The Other Person”The Other Person”– Observer – what went well, what Observer – what went well, what

could be improvedcould be improved

Final Thoughts?Final Thoughts?

• Sources Sources – Achieving Safe and Reliable Healthcare: Achieving Safe and Reliable Healthcare:

Strategies and Solutions, Strategies and Solutions, Leonard, M., Leonard, M., Frankel, A., Simmonds, T, 2004.Frankel, A., Simmonds, T, 2004.

– Crucial Conversations. Patterson, K., Crucial Conversations. Patterson, K., Grenny, J., McMillan, R., Switzler, A., 2002.Grenny, J., McMillan, R., Switzler, A., 2002.

– Silence Kills, www.vitalsmarts.com, 2005Silence Kills, www.vitalsmarts.com, 2005– ManageMentor on Giving and Receiving ManageMentor on Giving and Receiving

FeedbackFeedback, Harvard Business School , Harvard Business School Publishing, 2003.Publishing, 2003.

– www.jointcommission.orgwww.jointcommission.org