Contributed by Duncan Kennedy

Athletes develop muscle memory on the field, musicians rehearse seated as they would in the orchestra pit, and soldiers train in battlefield conditions. Is being a healthcare professional somehow different in needing the ability to meld ability with application and awareness?

For many healthcare professionals, though, learning new information, skills, and procedures often involves leaving the workplace environment in order to attend classes or access online instruction elsewhere onsite. While both facilitator-led instruction and online learning are proven and accepted forms of training (when designed and delivered properly), training away from the action of the clinical setting is usually at the expense of the learner’s enjoyment, their engagement in the instruction, and their ability to sustain the training and successfully apply it later.

How many of us have been in a learning lab in front of a computer mindlessly clicking through bullet-point text screens trying to reach the end of the course just to earn a mandated “completion” status for the latest organization-wide initiative? How many of us have been pulled away from daily responsibilities only to be placed inside an instructional artifice and forced to multi-task by absorbing the learning, sifting through its relevance, and then visualizing how to apply the parts that are actually applicable to workplace reality? Perhaps worst of all, once we return back to our work environment we find that being away for training often includes a pile of work to catch up on that accumulated while we were gone – effectively doubling the impact that training away from the work environment has on productivity. Plus, most of time you train solo without your leader and team members.

Instead of commoditizing the learning experience in order to maximize throughput or bluntly leverage resources, what if the focus was on customizing the instruction to best suit the learner to maximize impact, application, and sustainment? Using story to engage the human mind – the most powerful simulator ever created – is a proven and universal way to stimulate learner visualization of applying the training at the same time it is being comprehended. This “time compression” of learning and visualization is compounded when it occurs in the environment where it will be applied. Learners are fully engaged and most receptive to important information, new behaviors being demonstrated, and how to take action in a situation. Immersing themselves inside the story and viscerally experiencing it while at the workplace melds the unfamiliarity of the instruction with the daily reality of their work environment. What may not have been done before seems that much easier to accomplish when you’ve already imagined yourself doing it in the place where you work.

Combining the power of story, with the real world setting of the actual workplace, and the ability to visualize and embed new behaviors and practices without distraction or artifice shortens the distance between training, implementation, practice and sustainment.

Contributed by Richard Stone

Kevin Kelley describes in What Technology Wants how we possessed the same brain power that we have today at least 100,000 years ago, but it was not until 50,000 years ago that we went from being a primitive species using only rudimentary tools to true innovators. This explosion of innovation occurred almost overnight, concurrent with the arrival of language. Homo sapiens went from using sharp rocks at best, to the development of finely hewn knives, carved figurines, and hearths. Some might say that the use of tools led to the development of our language skills, but it’s more likely that the development of language – and more specifically, storytelling skills – was at the heart of the avalanche of inventions and discoveries that still continues 50,000 years later.

Why was storytelling so pivotal in assisting humans to consistently discover new solutions to life’s challenges? Kelly suggests that storytelling assisted our predecessors because it allowed tribesmen to convey to each other insights and inventions quickly, and to transfer knowledge easily. It proved to be the basis for most every innovation that followed—and each innovation became the foundation for new and more involved discoveries.

What is the significance of this phenomenon for healthcare organizations today? Hospitals that have a vehicle for their tribe (nurses, doctors, techs, pharmacists, etc.) to share what they have learned about creating a safer and more pleasant experience for patients will more likely succeed in the increasingly competitive environment that is certain to see winners and losers in the coming years. While we no longer can gather around the “central fire” in today’s modern work setting, it has become more imperative than ever to create for your team members moments to gather and tell their stories, to share insights as well as cautionary tales about near misses, and to collectively innovate on the job. Learning can no longer be relegated to a structured event a few times a year. It must be ongoing, all encompassing, and inviting. And the best way to do that is still the one that our ancestors first used some 50,000 years ago—storytelling.

Contributed by
Richard Stone

Continuing with my dad’s saga in the healthcare system…

After 9 days in the hospital precipitated by pain and discomfort extending from his chest to his abdomen (which led to a visit to the ED, hospitalization and a score of tests which all came up negative), they discovered during his stay that his atrial fib was not being properly regulated by the drug he was on. The pacemaker they installed just a few weeks previously was doing its job to keep his heart beat around 70, but he was getting abnormal spikes in rate sometimes up to 130 just walking down the hall. Increased dosages of the drug didn’t work, nor did increased frequency. So he sat and waited for the past few days for his clinicians to come up with a solution.

Even though he’s soon turning 97, his mind is still as sharp as a tack, as are his observational skills. Nothing escapes him, and the litany of mistakes and dis-satisfiers he noticed became a daily occurrence. The other night in my daily call to him he gave me his report. I believe they are instructive, but perhaps a bigger question is whether or not his observations and insights will ever make their way back to the hospital’s leadership, much less his care team so they can improve their performance.

Because of his age they are rightly concerned he might fall. He had firm instructions that he wasn’t to leave the bed without assistance, and they had him monitored to alert the staff if he attempted to make an escape from bed without them. Needing to use the bathroom, he called the desk. His tech answered. She said she had just two tasks and she’d be right there in five minutes. Forty five minutes later she still hadn’t shown so he got up and took himself to the bathroom. Apparently the alarm never went off because she showed up a few minutes later wanting to know if he was ready for the bathroom.

Another night, he asked for assistance to help him into the bathroom so he could brush his teeth and use three other tools the dentist recommended—a half hour ritual. So, his tech got him a seat so he didn’t have to stand. When he stood, his socks with the non-skid ridges stuck to the floor. My dad used to be in the janitorial business and he has watched as his room has been cleaned (and on some days not). They now use a device similar to the Swiffers that we can all buy in the grocery store. In the old days, his crews would have first cleaned the floor and then mopped with clean water to clean up the residue. Whatever the residue that is left on the floor by this new cleaning method may, for all I know, leave an antimicrobial barrier. But as far as he is concerned, since his socks were sticking to the floor … it wasn’t clean. This is a reminder that when it comes to patient satisfaction, perception equals reality.

Getting to his age, he’s got lots of meds in addition to those that are supposed to regulate his heart. Some need to be taken a half hour before eating, others an hour after breakfast. Consistently nurses or techs have either brought him all of the capsules at one time—usually the wrong time for many of the drugs. Or, as was the case yesterday, a nurse woke him at 5:30 AM for his drug that’s supposed to be taken a half-hour before breakfast. He asked her why she woke him up so early since breakfast had never arrived earlier than 8:30 during his many stays there. Why couldn’t she just come in at 7:30 and let him sleep? Her response: doctor’s orders. He was dubious. And now exhausted. The truth was more likely nurse’s convenience. He wondered why his care was so unpredictable from day to day?

I asked him if he had ever filled out a satisfaction survey after his many hospitalizations that began this past summer. Yes he had—sounded like it wasn’t HCAHPS given the length of the survey he described. Did he give the hospital poor marks? No, he wanted to be generous.

Then the other day someone from the hospital appeared at his bedside wanting to interview him about his experience there. All he could think is that if he told the truth, word would get back to his care team, and he wondered whether it would change their attitude toward him—for the worse. His response: everything’s been fine.

I went on hospitalcompare.gov to check out this facility’s HCAHPS scores. Consistently they scored below the Florida average, and well below the national average.

I wonder if anyone there is genuinely seeking the truth, and if they do find it, what are they doing to help their teams learn and improve?

Contributed by Richard Stone

Over the last few months, I have had the opportunity to see our healthcare system up close and personal as my dad, soon to be 97 years old, traversed through it with the first major health crises in his life. It started a couple years ago when he decided to rearrange the boxes in his condo’s storage bin. I came by one weekend and he wanted me to take some things, so I had to lift some extremely heavy boxes off a top shelf. When I inquired how they got up there he informed me he put them there. Interestingly, just a few weeks previously he had been complaining of abdominal pain and had been diagnosed with an inguinal hernia. When I asked at that time how in the world he had gotten a hernia he pleaded ignorance. But as I stood there in his storage area I put it all together and looked at him in disbelief. “I know how you got a hernia, you clod, you lifted these boxes all by yourself.” He was a bit sheepish when confronted with the fact that there are some things he simply shouldn’t be trying at his age.

Well, a few months ago he decided to get the hernia repaired. Something like this is now done in one day as an outpatient procedure, so I came over to support him and his wife. I kiddingly joked with his surgeon when he stopped by the pre-op area to check on him that my dad must be the oldest person he’s ever operated on for a hernia. I was wrong. He had done a repair on a woman who was 106!

Post surgery, I sat with my dad and his wife in a small curtained off area as the discharge nurse went over everything he needed to know to care for the surgical site. He had made it clear before the surgery that he often doesn’t do well with narcotic pain relievers, getting easily constipated, but who looks at charts these days? She gave him a Percocet and a prescription and sent us on our way, encouraging him to eat lots of prunes when he voiced his concern.

Sure enough, a couple days elapsed and he was severely constipated. A call to his surgeon resulted in some encouragement to eat more prunes. Another day or two passed and he was still constipated, and in a lot of discomfort, so now it was time for an emergency room visit. More admonishments to eat fruit, plus a script for a stool softener. Three days later he was back at another ER for a procedure to relieve him of bowel impaction.

I don’t know what the final tally was for all the medical bills for these aftercare visits that all could have easily been avoided—surely in the tens of thousands. All unnecessary. All preventable. But the charge nurse who originally administered the Percocet will never learn from this event. The first ER won’t either, just as the second ER won’t. They are all independent actors on a stage with sets separated by immensely high walls and lots of sound proofing.

Five weeks later my dad took a fall and broke 6 ribs. Even drove himself to the hospital. But that’s another aspect of the ongoing story of waste and mismanagement inherent in healthcare that I’ll share with you in an upcoming blog.

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.