Contributed by Richard Stone

From one perspective, a hospital can be viewed as a beehive of intersecting and shared stories. First, a patient arrives at the front door with a history, both personal and health wise, and the trajectory of their personal narrative can be fundamentally altered by the outcome of what occurs during their health crisis. It can be just a blip on the calendar: an interesting tale to be told about getting stitches for a cut or a false alert about chest pains. And the individual picks up where they left off, now with an entertaining story to be told at a dinner party.

Or, the health event can be so serious that it irrevocably alters the path of their lives. A good friend of mine who is a triathlete collapsed one evening two years ago with a hemorrhagic stroke. He barely survived and for the next two years took on his rehabilitation as though he was training for the race of his life, and clawed his way back to nearly 100% of where he was before the stroke. He was desperately attempting to reconstruct the narrative that he dearly associated with his identity—an athlete, a gifted corporate trainer, and a person who was witty and filled with nuance. He was back to jogging, swimming, lifting weights, and other than nearly imperceptible remnants of aphasia, he had returned to the classroom and was warmly received by professionals and admired for his courage. Then, the night before he was to deliver his first solo training since the stroke to the leaders of a major company, he was stricken with a second stroke. The story of how he returns from this new challenge is still to be written, but I can say that this mountain seems even more daunting to him than the first.  Knowing his gritty personality, I suspect he will fight his way back.

These personal narratives that patients bring with them are like fragile glass vessels. While healthcare professionals dwell on the clinical narrative, this more important narrative is continuously developing whether they recognize it or not. Those nurses and doctors and housekeepers and techs who understand and appreciate the importance of the patient’s story are equipped to provide a level of healing that transcends all of their clinical expertise, and all that they do for a patient physically. For patient narratives that are shattered as in the case of my dear friend, they can also plant the seeds for reconstruction, or they can sow doubt and cement a narrative that is filled with despair and hopelessness.

A few days after my friend’s first stroke, his neurologist stepped out of the room after an examination and asked his wife what her plans were for him. She asked what he meant. He clarified—what nursing home are you going to place him in? This thought was not part of her narrative—she was planning on him recovering fully and becoming vibrant again. He attempted to dissuade her from this vision. Thank goodness she didn’t allow his story to usurp theirs.

What stories are we telling patients about their current circumstances, and what kind of vision are we painting with our words about their future story? While none of us wants to proffer false hope, we must be on guard that we are not unwittingly creating self-fulfilling prophesies of despair and demise as well.

Contributed by Richard Stone

In his seminal book Sense Making in Organizations, Karl Weick tells a fascinating story about a lieutenant in World War I who sends out a patrol into the French Alps to scout out the positions of the German troops. The small patrol took no provisions, because this was intended to be just a short search and they planned on returning to camp by nightfall. But about two hours into their trek it began to snow—so hard that it was soon a white out and the soldiers could barely see their hands in front of their faces. They were in trouble. Their leader led them to a small overhang in the side of a mountain where they settled in, hoping that the snowfall would break by late afternoon. But it continued to snow through the day, into the night, and for the remainder of the next day. It was one of those blizzards that comes around only every 500 years or so. By the end of the second day the team had gone through all their provisions and were growing hungry. Huddled together under that cliff to share their dissipating warmth, their hope for survival was growing bleaker by the moment. On the morning of the third day the snow was beginning to let up, but without any clear landmarks that hadn’t been obliterated by the 50 inch snowfall, they were lost and mentally preparing to die in the wilderness. One of the soldiers decided to rummage through his pack hoping to find some morsel of food that he might have overseen. There, folded at the bottom was an old map of the Alps. When he announced that he had found a map everyone’s spirits were buoyed. They made a decision to head out in the hopes of reconnecting with their regiment. Continually referring to the map for clues as to where they were, they slowly made their way through the drifts. Finally at nightfall one of them saw the glow of a light in the distance. They had found their way home. After the reunion and as his men warmed themselves by a fire and ate like they had never eaten before, their commander was curious about how they had escaped a frozen fate. He asked to see the map they had used. Examining it by his lantern, he looked closer to discover that this was in fact not a map of the Alps, but a map of the Pyrenees!

While there are questions about the veracity of this story, the question still arises in the context of the story how they used an incorrect map to navigate their way home? Weick suggests that the map served as a catalyst for action, getting them moving and re-committing to set out and make sense of their journey along the way.

Such a conclusion is a strange conundrum. Certainly without the map they would never have set out to discover a new way home. It was indispensable.

As your teams set out into strange territory to remake healthcare and make it a safer and more satisfying experience, stories can act just like a map, acting as a catalyst that gets us thinking and making sense of our current circumstances, examining our assumptions about reality, revising those beliefs that are erroneous, getting us to see again what has become habitual, and making adaptations that can help us get to a new destination.

Contributed by Richard Stone

There’s a familiar saying that gets bantered about these days when things don’t change – Question: What’s the definition of insanity? Answer: Doing the same thing over and over again and expecting different results. Hospitals, like so many of us, suffer from this form of myopia. Little has changed in the past hundred years when it comes to role definitions. Managers continue to manage with other priorities being top of mind instead of how their actions contribute or detract from the safety and satisfaction of patients. It’s no wonder—there are so many things to keep track of. Staffing requirements, compliance with a whole host of ever changing regulations, pressures on nurses and other caregivers to handle the care of more and more patients, not to speak of the intermittent crises that emerge almost daily when the care continuum breaks down. In many healthcare facilities, the ship is sinking under the weight of these demands, yet managers continue to hold steady to their familiar course, hoping that with time they can weather the storm, saying to themselves, “If we can just bail a little faster, we’ll make it to tomorrow!”

I suggest that first we need to reexamine one of the most important new roles that has emerged in healthcare settings in the last 20 years—that of the quality improvement manager. Step one is to eliminate the position of “quality improvement manager”. That may seem harsh, but I contend that the organization does not need one person attempting to engender improvement from the top. Lasting improvement like all social change of any consequence comes from the bottom, emerging from the rank and file.

Step two, give everyone of your team leaders and managers an additional title—Quality Improvement Manager. Put it in their job descriptions. Incorporate it as a top priority in performance reviews. Compensate them for results. Hold them accountable if they can’t achieve results. Define the skills they need to succeed and provide them the tools and resources to continually improve. Hire people who fit this job profile and expect results starting on day one.

You will have now sent a message to every member of your management team that doing the same old things and expecting different results will no longer cut it. Be as bold in your expectations as your patients are of your institution. Leadership is a verb, not a noun. In doing the above, you’ll find that innovation and ownership will take immediate hold with a lasting and sustainable impact.

Contributed by Steve Powell

Each of us spends varying amounts of time in front of the mirror each day preparing, comparing, and analyzing our appearance related to a standard we have set for ourselves.  Seeing our reflection, we quickly receive feedback, make adjustments and perfect our look whether it is our hair, makeup or proper clothes.

This daily ritual is a just that—a ritual or habit; repetitive and automatic.  We wouldn’t leave the house without our daily ‘reflection’.  What other reflective activities can be used to produce continuous improvement?  Effective, high performing teams use a very specific feedback event known as the ‘debrief’ to reflect past team performance and promote experiential learning.  Debriefs are short-lived instances where teams face the ‘mirror’ (each other) to reflect valuable insights, knowledge, and shared understandings designed to optimize performance.

In a debrief team members get a chance to review decision-making, timing, efficiency, and effectiveness along with identifying opportunities for remediation, self-correction, and new goal-setting.  Debriefs are designed to be diagnostic, solution-based, critical thinking exercises.  Teams attempt to reconstruct the ‘who’, ‘what’, ‘where’ and ‘why’ of a past experience whether in real-time or in simulation.  To properly diagnose, they must be aware and attentive to performance deviations.  Furthermore, teams must be able to trust each other enough during debriefs to be able to openly critique, not criticize.

Discussing and learning from positive and negative behavioral experiences is an effective way for teams to perform new tasks and perfect difficult tasks in the future.  In fact, reviewing the ultimate outcome of the experience may not be as beneficial as reviewing the process that led to the outcome since teamwork doesn’t happen without a ‘taskwork’ context.

The debrief can be practiced with another team directly observing actual events or simulated activities like high fidelity mannequin drills, role plays, or recorded vignettes.   Simulated vignettes, either video, audio or case-based scenarios, offer teams the ‘psychologically-safe’ opportunity to objectively reflect on the performance of other teams before debriefing their own performance.

When used regularly, like the daily time in front of the mirror, debriefs are a powerful, yet simple tool for continuous team improvement.  Start with three simple questions:  What went well? What didn’t go well? And, what could we do better the next time?  It’s only through reflection that flaws can be addressed and assets leveraged.

Contributed by Duncan Kennedy

To some, the notion of using “story” or the act of “storytelling” as a tool for organizational change may seem new or even novel. But humankind has been using stories to communicate within and across organizations for thousands of years. In many ways, “story” is the original tool of transformation.

Think back to the earliest form of organizational identity – the tribe. After departing Egypt, Moses delegated authority to the elders of the Israelites to listen to disputes, creating a hierarchy that ultimately reported back to him, creating what is probably the earliest known example of an organization. Looking closer to home, the native peoples who inhabited this continent prior to the arrival of Europeans had a rich tradition of using stories to impart knowledge across the generations for the ongoing benefit and sustainment of the group – where and at what time of year were the best hunting grounds, how was the best way to track and capture prey, how to safely clean and prepare meals, and even what other groups to give a wide berth to avoid trouble. Story was how chieftains, shamans, lead hunters, and matriarchs shared the established understandings of the tribe, introduced new ideas and discoveries, and taught younger members how to behave properly and contribute quickly.

What’s interesting about this is that for many generations, it was done without the benefit of formal language. It was acted out in dance and pantomime as important rituals that codified tribal knowledge, valuable experience, and mutual understanding. Clans also used artistic depictions and symbols to represent their most valued experiences and learning. With the advent of oral communication and language, story remained the constant modality for expressing concepts and behaviors. And we must be reminded that only recently in human history did the use of symbols and characters evolve to record experiences on tablets and parchment, creating a permanent record that was not as vulnerable to extinction as is the oral tradition.

With the introduction of industry, modern technology, and now a climate of constant information, “story” has fallen behind the times in the eyes of some. Yet all we need do is sit through an excruciating PowerPoint presentation to recognize how meager contemporary communication tools are in comparison to the ways that stories engage us. The power of story is that it cuts across all manner of format, lexicon, and complexity. Everyone can tell, listen to, and understand a story. It is a universal trait of humanity. We do it every day. We do it with friends and family. We do it with colleagues and peers. We do it with children and students. Some of us may be more confident at it than others. Some of us may be more entertaining than others. But the ability to both share and experience a story are like core programs written deeply into the subroutine of our specie’s mental functioning. There is significant research to point to the fact that we have narrative schemas in our mind that predispose us to seek out and attend to “storied” information. Once information becomes more didactic and linear, our minds are wont to wander. Moreover, a growing body of research points to the fact that our capacity for storytelling is literally encoded in our DNA.

All you need to do is start telling a story to someone from another culture to see how it immediately cuts across differences in language, ethos, and traditions, immediately forming a bond between the teller and the listener. In fact, powerful stories can tear down the barriers to understanding that frequently alienate and separate us, creating the ground for rapprochement and healing among peoples who have long histories of vilifying each other, creating new possibilities for collaboration, transforming hatred into understanding.

Contributed  by Steve Powell

At the recent Society of Simulation in Healthcare (SSH) annual meeting, over 4,000 healthcare professionals gathered to network, share and learn best practices related to the use of simulation.  The uses of simulation in healthcare include knowledge and skill building in professional education and performance improvement across the healthcare environment.  The ‘simulator’ has become the center of attention in the simulation industry with most of the research and development poured into creating a more high tech or realistic experience.  This level of realism is known in the simulation jargon as fidelity or the ‘suspension of disbelief’.  When you say the word ‘simulation’, most healthcare professionals immediate think of ‘talking’ mannequins that breathe, bleed, react and respond to clinical actions through a set of complex, computer programmed actions during a laboratory or classroom-based session.  The exhibitors at the conference are dominated by manufacturers that create these types of simulators and all the supporting technology to create a ‘lifelike’ experience for maximum learning.  But, is this type of simulation the only way to maximize fidelity or maximize learning?

In fact, simulation fidelity relies on different elements to be mixed to create the ideal experience for learners based on 1) the equipment (the type of simulation device), 2) the environment (the sensory activation like visual and auditory cues), and 3) the psychological fidelity (how closely the training scenario matches reality).  Behavior-based training such as teamwork, communication, professional behavior, patient engagement, conflict management, feedback, decision-making and clinical leadership have all been shown to be effectively simulated using lower fidelity methods such as case studies and role-plays.  Many of the educational sessions at the conference focused on the use of ‘human simulation’ also known as ‘Standardized Patients’ (SP) in medical education for teaching assessment and treatment skills to medical students in a simulated treatment room through a scripted role-play.  The SP is a trained actor who puts on a hospital gown and simulates that they are ill and in need of medical attention based upon a scenario designed to achieve learning outcomes.  Often times, the encounter is videotaped and participants have an opportunity to review their performance in a post-event debrief.  High fidelity mannequins and SP actors are both effective simulation strategies but have limitations due to cost and scalability across an entire health organization and multi-disciplinary continuum (physicians, nurses, administrators, technicians and other staff).

Almost absent from the recent simulation conference was the effective use of case studies that do not rely on equipment; engaging stories that feel real because they are based upon real occurrences (psychological fidelity) and are sound engineered to produce a realistic sensory experience (environment fidelity).  These types of simulation are lower in equipment fidelity; but when coupled with team debrief, can produce team learning outcomes that are scalable and less resource intensive, meaning less costly to train, less time to train, and overall lower training complexity.

So, when thinking of developing an effective simulation training program for improving individual and team skills in healthcare, educators and facilitators should consider other factors instead of just the simulation equipment to create adequate realism to achieve organizational training goals and learning outcomes.

Contributed by Richard Stone

There’s an old moniker that is accepted wisdom when it comes to presenting ideas to groups you’d like to convince to change: Tell Them, Tell Them What You Told Them, And Then Tell Them Again. Western cultures also have a tradition to moralize at the conclusion of fables—“therefore children, don’t ever go into those deep dark woods by yourselves because…” Inherent in both of these approaches is the belief that combining the story or the message with an admonishment will ensure that the listener will learn or change their behavior.

If such approaches were indeed truly effective, this would be a better world, and all healthcare leaders would have to do is tell their teams three times to adopt behaviors that keep patients safe, and like magic, all errors and disgruntled patients would evaporate. Unfortunately, such approaches don’t succeed despite the best of intentions. Why?

Native Americans have had millenia to learn about how to persuade people and how to deal with powerful forces of change that could upend their world in the breath of a moment. They came to understand that learning was the most important and valuable function to ensure the resilience of their people and the perpetuation of their culture. Interestingly, they had no word for teacher in the way we understand teaching. The closest translation for their terminology would be “enabler of learning.” Needless to say, they studied closely how people learned best. Before anyone in this world received an advanced degree in cognitive psychology, the Oneida people came to see that one of the most powerful tools available to a communicator to engage listeners in learning was a simple question, not an answer. As a result, they developed a tradition of learning stories that were meant to engender questions, not answer them. Raise issues, not resolve them. The most powerful question that they designed at the conclusion of a story is simple and elegant by design, yet more potent than any of us can imagine: What might we learn from this story?

When people come together to listen to a story who are challenged by serious issues related to keeping patients safe or satisfied, and then are asked what they might learn from the story without the teller directing their learning, something remarkable is unleashed—the creativity and engagement of every team member. By catalyzing the power of teams to make a difference in the spirit of learning, true transformation becomes possible, and perhaps, inevitable.