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It Starts With a Cup of Coffee

It Starts With a Cup of Coffee. Gerald B. Hickson, MD Assistant Vice Chancellor for Health Affairs Associate Dean for Faculty Affairs Joseph C. Ross Chair in Medical Education & Administration Center for Patient & Professional Advocacy, Vanderbilt University School of Medicine.

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It Starts With a Cup of Coffee

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  1. It Starts With a Cup of Coffee Gerald B. Hickson, MD Assistant Vice Chancellor for Health Affairs Associate Dean for Faculty Affairs Joseph C. Ross Chair in Medical Education & Administration Center for Patient & Professional Advocacy, Vanderbilt University School of Medicine

  2. Professionalism and Self-Regulation • Professionals commit to: • Technical and cognitive competence • Professionals also commit to: • Clear and effective communication • Modeling respect • Being available • “Self awareness” • Professionalism promotes teamwork • Professionalism demands self and group regulation • You have a critical role Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

  3. Awareness conversations work. But can’t we address issues earlier? Do we have to wait for pattern development?

  4. Promoting Professionalism Pyramid Mandated Reviews Adapted from Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007 Level 3 "Disciplinary" Intervention No ∆ Pattern persists Level 2 “Guided" Intervention by Authority Apparent pattern Level 1 "Awareness" Intervention "Informal" Cup of Coffee Intervention Single “unprofessional" incidents (merit?) Egregious Mandated Vast majority of professionals - no issues - provide feedback on progress

  5. For a single “event”… Regular and Espresso

  6. Case: “Hand washing” • You, a charge nurse, observe your colleague, a consulting specialist, enter the ICU to check on a patient…you notice the colleague begins examining the pt. without foaming in… • You are aware there is an organization-wide initiative to improve hand hygiene adherence… • You decide to have a conversation with the colleague…

  7. What might an “informal” intervention - a “cup of coffee” conversation - sound/look like?Can anyone have these conversations with anyone?

  8. Principles for “Informal” Conversations • Approach using same principles as for giving bad news to patients - maintain trust and respect • Minimize distractions (have in private or semi-private area if possible) • Avoid tendency to downplay seriousness • Balance empathy and objectivity • Anticipate range of responses (push-backs) – from rage to non-response

  9. Principles for “Informal” Conversations • Your role (even as “the chief”): • To report an event • To let the colleague know that the behavior/action was noticed (surveillance) • It’s not a control contest. (“I am coming to you as a colleague…”) • Don’t expect thanks (acknowledgement) • Know message and “stay on message” • Know your natural default (your communication style; your “buttons”)

  10. Opening the Conversation • Offer appreciation (if you can): “You’re important, if you weren't, I wouldn't be here.” • Use “I” statements: “I heard…,” “I saw…,” “I received…” • Review incident, provide appropriate specifics • Ask for colleague’s view…pause… • Respond to questions, concerns…

  11. Ending the Discussion • Appreciation, affirmation • Empathy: “Now I feel I understand..." • Accountability: "But we've all got to respond professionally..." • Reminder of behavior standards: “incident did not appear consistent with..." • If asked what to do use phrases: "reflect on the issues, think about ways to prevent recurrence." • If appropriate, Assure: conversation confidential, known only to…

  12. A “Cup of Coffee” Conversation Is Not: • A control contest • Therapy (for the individual or yourself) • A hierarchical conversation • An enabling conversation • An opportunity to address multiple other issues

  13. Now it’s your turn…

  14. Cup of Coffee Role Plays • Please divide yourselves into groups of three • Each group of three is given a packet of handouts • Each group will role play a cup of coffee conversation • Each person should play one of the parts: • Professional having the conversation: have a cup of coffee conversation • Person with performance issue: read your role before beginning • Observer: use the checklist provided

  15. What did you experience? Observe?

  16. Other Observations • Less is more: • How was the ‘message’ conveyed? • How many times was the message repeated? • How were the pushbacks handled? • How long was the conversation? • Was the person conveying the ‘message’ too empathetic (e.g., minimize the number or types of complaints, accept excuses without suggesting going back to the event or data, etc.)?

  17. Other Observations • Did the messenger use language that was directive or judgmental (gave advice, recommended, indicated condescension or a “holier than thou” attitude, use adjectives or adverbs, etc)? • Did the messenger come back to the main point despite pushbacks? • Did the opening and closing portions of the conversation “work”? • Was any part of the conversation omitted?

  18. What if you are the boss?Can a boss ever share a cup of coffee with someone who reports to them?

  19. Case: “No thank you” • The following event is reported to the you, the Division Chief, via the organization’s electronic reporting system: • “Dr. __ entered the room without foaming in…proceeded to touch area with purulent drainage…I offered a pair of gloves…he took them and dropped them into the trash can with the patient watching.” • As the Division Chief you have a responsibility to follow up with such reports…Because this represents a potential safety issue, you decide to have a conversation with Dr._ • You want to approach collegially, but with something more than a regular Cup of Coffee

  20. Absolutely. For leaders, there are two kinds:RegularEspresso

  21. Principles for Espresso Conversations • Same as the cup of coffee EXCEPT: • As your leader…let you know that the behavior/action was noticed • “Is the report factually true?” • Documentation – but please declare, “I will drop a note…”

  22. Now it’s your turn…

  23. Espresso Role Plays • Rotate roles among your group • Please divide yourselves into groups of three • Each group of three is given a packet of handouts • Each group will role play an Espresso conversation • Each person should play one of the parts: • Authority Figure: have an espresso conversation • Person with performance issue: read your role before beginning • Observer: use the checklist provided

  24. What did you experience? Observe?

  25. Handy Intervention Phrases You might be right…but… I just have to wonder … I am here to deliver the message. If these were my data, I would want to know. I hear your concerns about systems/policies (etc). Please help identify and implement solutions as well.

  26. What about the use of the word “but”?

  27. What about the use of the word “but”? As a leader, you are not negotiating or mediating…

  28. Guiding Principles for Action Reiter CE, Hickson GB, Pichert JW. Addressing behavior and performance issues that threaten quality and patient safety: What your attorneys want you to know. Prog Pediatr Cardio. 2012; 33:37-45. Justice Certainty Insight Redemption No Conflict of Interest

  29. Do you document the conversation?All?Some?

  30. Documentation: How • Should be a record of direct, personal communication (no nasty grams) • Be objective • Avoid adjectives • Talk about the event, not the person • Make sure it’s true and not misleading • How would it look projected on the courtroom wall? Reiter CE, Hickson GB, Pichert JW. Addressing behavior and performance issues that threaten quality and patient safety: What your attorneys want you to know. Prog Pediatr Cardio. 2012; 33:37-45.

  31. But what if all efforts fail?

  32. Promoting Professionalism Pyramid Mandated Reviews Adapted from Hickson GB, Pichert JW, Webb LE, Gabbe SG. Acad Med. Nov, 2007. Level 3 "Disciplinary" Intervention No ∆ Pattern persists Level 2 “Guided" Intervention by Authority Apparent pattern Level 1 "Awareness" Intervention "Informal" Cup of Coffee Intervention Single “unprofessional" incidents (merit?) Egregious Mandated Vast majority of professionals - no issues - provide feedback on progress

  33. Infrastructure for Promoting Reliability & Professional Accountability (PA) • Leadership commitment • Goals, a credo, and supportive policies • Surveillance tools to capture observations/data • Processes for reviewing observations/data • Model to guide graduated interventions • Multi-level professional/leader training • Resources to help address unnecessary variation • Resources to help those affected Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring and addressing unprofessional behaviors. Academic Medicine. 2007. Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

  34. Consider your next initiative. Is there a plan for addressing unnecessary variation in faulty systems and human performance?

  35. Professionalism and Self-Regulation • Professionals commit to: • Technical and cognitive competence • Professionals also commit to: • Clear and effective communication • Modeling respect • Being available • “Self awareness” • Professionalism promotes teamwork • Professionalism demands self and group regulation • You have a critical role Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

  36. How CPPA works with partners to equip to address unnecessary variation in performance • Institution/system/collaborative-wide readiness assessments, gap analysis on infrastructure required to address unnecessary variations • Facilitation of dedicated work groups to address gaps • Leadership skills development in the CPPA tiered intervention process with training of trainers to foster dissemination • Support tiered interventions with feedback-related letters, data, graphics, etc, and dealing with pushbacks, institutional politics, reporting

  37. “CPPA Tool and Process,” and Results

  38. Upcoming CPPA Conferences • Promoting Professional Accountability: Dealing with Behaviors That Undermine A Culture of Safety • June 21-22, 2012; September 13-14, 2012 • The How and When of Communicating Adverse Outcomes and Errors • October 5, 2012 http://www.mc.vanderbilt.edu/centers/cppa/courses.htm

  39. Let Us Hear Your Comments and Questions Now or Laterwww.mc.vanderbilt.edu/cppa

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