A Chasm of Disconnect: Community, Motivation, and the Patient: Part Two

In his book Punished by Rewards, Alfie Kohn systematically destroys the myth that awards (extrinsic motivation), whether financial in the sense of pay-for-performance, or gold stars for the good behavior of children, succeeds at achieving their intended effect. In fact, the evidence overwhelmingly suggests that rewards fail miserably in efforts to induce lasting change.⁴ Kohn cites multiple studies that support this conclusion:

• Undergraduate students who were asked to perform certain tasks without compensation performed the tasks significantly better than those who received compensation
• The performance of college students who were paid for turning out school newspaper headlines stopped improving, while those who were not paid continued to get better
• Fourth graders who were asked to perform a task they “liked” performed poorly at the same task when offered toys or candy as a reward for doing the task

Kohn cites many other studies. Rewards—extrinsic motivations—significantly affect not only the quantity of one’s work, but also the quality of the work. While the provider may be thinking, “Well, medicine is different,” the data does not support that conclusion. In fact, mere observation reveals to me—and probably most of us—the effects of rewards in medicine are no different than any other profession.

Intrinsic motivation, conversely, is a powerful predictor of work quality and success. Koestner has noted:^{5 (p. 389)}

Intrinsically motivated people function in performance settings much the same way as those high in achievement motivation do: They pursue optimal challenges, display greater innovativeness, and tend to perform better under challenging conditions.

In simple language, “extrinsic motivators are a poor substitute for genuine interest in what one is doing.” But Kohn points out an even more frightening fact:^{4 (p. 69)}

What is likely to be far more surprising and disturbing is the further point that rewards, like punishments, actually undermine the intrinsic motivation that promotes optimal performance.

In other words, even when an individual enjoys a particular job and is intrinsically motivated, providing extrinsic rewards to that individual to do the work results in reduced motivation to do the very work they were previously motivated to do, and a reduction in the quality of the results obtained. Who reading this book has not experienced the phenomenon that, at sometime in our past, we used to do something that we enjoyed—until we started getting paid for it? Think of the fact that, not to long ago, physicians took ER call because it was part of their duty to have medical staff privileges and in service to the community. Now, in many places, physicians will take call only if they are paid, if they provide this service at all. Once you started getting paid for engaging in the activity (after which point you would no longer consider doing it for “free”) your intrinsic motivation was gone, or at least substantially diminished. Kohn uses an “old joke” to illustrate this very point:^{4 (pp. 71-72)}

It is the story of an elderly man who endured the insults of a crowd of ten-year-olds each day as they passed his house on their way home from school. One afternoon, after listening to another round of jeers about how stupid and ugly and bald he was, the man came up with a plan. He met the children on his lawn the following Monday and announced that anyone who came back the next day and yelled rude comments about him would receive a dollar. Amazed and excited, they showed up even earlier on Tuesday, hollering epithets for all they were worth. True to his word, the old man ambled out and paid everyone. “Do the same tomorrow,” he told them, “and you’ll get twenty-five cents for your trouble.” The kids thought that was still pretty good and turned out again on Wednesday to taunt him. At the first catcall, he walked over with a roll of quarters and again paid off his hecklers. “From now on, he announced, “I can give you only a penny for doing this.” The kids looked at each other in disbelief. “A penny?” they repeated scornfully. “Forget it!” And they never came back again.

He sapped their intrinsic motivation with reward!

The basic premise of this story—the fact that the old man began to pay the children for something they had been doing voluntarily, something they thought was fun changed the manner in which they viewed the activity. Suddenly, “they came to seem themselves as harassing him in order to get paid,” not because they enjoyed the activity. The old man’s goal, and in fact, the result, was to sap the kid’s intrinsic motivation.

This premise is directly relevant to medicine today. It is my belief that almost everyone goes into medicine driven by a substantial degree of intrinsic motivation, whether it be scientific interest, interest in doing good for humanity or Dee Hock’s community. But in the process of accumulating over $100,000 of educational debt getting a medical degree,⁶ students and residents seeing the money that physicians make in the form of clothes, cars, houses and other accoutrements of wealth, and listening to physicians complain about the discrepancy between what they get and what they really deserve, our profession goes a long way in sapping the intrinsic motivation of our medical school graduates and residents before they are ever out of training.   They graduate with expectations of extrinsic rewards that can never be met and that are virtually without end. What was once an intrinsically motivated passion becomes a job that doesn’t pay me what I am “really worth.”

As I reflect on my own medical education and transition from medical school, to residency, to fellowship, and practice, I can’t tell you when this conversion happened to me, but it surely did. I can also tell you I did not, and do not feel very good about allowing myself to fall into that trap. And I can’t abdicate the responsibility for having allowed this to happen. I can’t blame it on Medicare, Blue Cross, the HMOs, society or anyone else. It is my opinion that the loss of intrinsic motivation due to extrinsic rewards is the primary reason we have a profession stuffed with successful individuals, who are not happy or fulfilled in what they do… their intrinsic motivation get sapped in the process of becoming a physician. If physicians truly did what they did because they loved their profession, why would the average age of retirement from the profession have dropped from 67 to 61?⁷ Considering this is an average, it reflects many physicians are retiring at a very young age.

Up next in the Communication Series: Ethnicity

All content from Civil Leadership, by Michael S. Woods. © 2007. All rights reserved.

References

4. Kohn, A: Punished by Rewards. New York: Houghton Mifflin, 1993.

5. Koestner, R., Zuckerman, M. & Koestner, J.: Praise, involvement and intrinsic motivation, Journal of Personality and Social Psychology, 1987, 53: 383-390

6. Association of American Medical Colleges: Medical School Graduation Questionnaire, All Schools Report. Washington, DC: AAMC, 2000.

7. Health Forum, Inc.: Doctor dearth: Frustrated with managed care and flush with wise investment, physicians are retiring earlier — alarming hospitals and practices. Hospitals & Health Networks, Vol. 75, No. 3, March 2001.

A Chasm of Disconnect: Community, Motivation, and the Patient: Part One

The engine for growth is patient perceptions. The engine for efficiency is process improvement.^{1 (p. 13)}

— Fred Lee

Today I’m stepping back from the communication in healthcare series, and circling back on leadership in healthcare.

When we think of relationships in our personal lives, the thought is not associated, at least one would hope, with an eye toward financial gain. Relationship-based civil leadership is based on the relatively straightforward belief that the effective relationship is, by itself, a valuable intrinsic reward. In health care, a culture suffused in relationship-based civil leadership benefit the organization with quality and safety and satisfaction levels unachievable in the business-as-usual environments.

A closer look at the evolution of the medical culture over the past 30 years and the extrinsic financial motivations of today that systematically replaced our forefather’s intrinsic motivations provides us with a contrast so bright that the need for relationship-based civil leadership as a critical focus in health care culture is undeniable.

This post highlights some critical barriers to gaining broad commitment to efforts at infusing relationship-based civil leadership in health care organizations today. I would suggest that the intent of health care providers in doing what they do is important to the topic of both relationships and civility.

Confusing Money and Motivation

What is our motivation as health care providers? Is everything we do something that must be paid for? Is compensation the driver of our being? The concept of non-monetary value is something many in health care have never learned—or perhaps more accurately, we have un-learned it. Non-monetary value is something or some activity that one derives some form of gratification from that is not based upon the amount of money it either generates for the individual, or requires an individual to pay.

My thoughts on this topic emanate from the brilliance of Dee Hock. I wish I had even a reflected twinkle of the amount of brilliance this man has, but in the absence of my ability to be original along these lines, I am going to rely on Mr. Hock. In his book Birth of the Chaordic Age, he writes a great deal about value and community:^{2 (p. 42)}

One concept…I have puzzled over is an ancient, fundamental idea, the idea of community. The essence of community, its very heart and soul, is the nonmonetary exchange of value; things we do and share because we care for others, and for the good of the place. Community is composed of that which we don’t attempt to measure, for which we keep no record and ask no recompense. Most are things we cannot measure no matter how hard we try. Since they can’t be measured, they can’t be denominated in dollars, or barrels of oil, or bushels of corn—such things as respect, tolerance, love, trust, beauty—the supply of which is unbounded and unlimited. The nonmonetary exchange of value does not arise solely from altruistic motives. It arises from deep, intuitive, often subconscious understanding that self-interest is inseparably connected with community interest; that the individual good is inseparable from the good of the whole; that in some way, often beyond our understanding, all things are, at one and the same time, independent, interdependent, and intradependent—that the singular “one” is simultaneously the plural “one.” (my emphasis)

Our society has become extremely skilled at monetizing everything. We hear the statements suggesting this truism everyday: “For enough money, you can have anything.” “People will do anything if they are rewarded appropriately.” “I’m not paid enough to do that.” I could go on, but the reader has probably already generated several more of these examples in their own head. Think about how we speak about time: we earn it, spend it, and save it! “Time is money.”

Hock continues:^{2 (p. 43)}

Community is about benefit, not profit.

Community is not about profit. It is about benefit. We confuse them at our peril. When we attempt to monetize all value, we methodically disconnect people and destroy community. (my emphasis) 

The nonmonetary exchange of value is the most effective, constructive system ever devised. Evolution and nature have been perfecting it for thousands of millennia. It requires no currency, contracts, government, laws, courts, police, economists, lawyers, accountants. It does not require anointed or certified experts at all. It requires only ordinary, caring people.

What health care provider—whether physician, nurse, or technician—and what health care consumer, does not immediately understand the relevance to Hock’s insight as it relates to medicine? There is perhaps no profession where “the monetization of value” has been more misguided and abused than medicine. We—medicine and society—have put virtually an infinite number of price tags on life and health. I, as a health care consumer, value my health so highly that I will, in fact, pay large portions of my income to maintain it, or correct problems that arise. The question is “Should I have to?”  A weightier question is, however, for me as the health care provider: “Is this the way it should be?” Should everything I do—every bandage I change, every conversation I have or email I exchange with a patient, every waking moment I spend at work—be something that I must be paid for? Everything that used to fall under the concept of caring now has a DRG, CPT or ICD code so we can submit a bill.

In his book Healing the Wounds, David Hilfiker has an entire chapter entitled Money.^{3. (p. 183)} The final paragraph of the chapter reads:

Like the medieval monastic practitioners, many (I think even most) of us physicians entered medicine with the desire to serve our patients, to be altruistic healers sacrificing ourselves for their good. Clearly, even the servant should be paid for working, so there is nothing contradictory between some remuneration and our calling. Yet as the profession has become wealthier and wealthier, a contradiction has arisen. As we physicians accumulate wealth, as we earn more than we really need, we become entrepreneurs and can no longer hang on to our perception of ourselves as servants. Yet we are not willing to let it go either, to embrace the Hippocratic ideal of self-interest. So money becomes for us the hub of a very serious contradiction. At some hardly conscious level, my income proved paradoxically to be little more than an additional drain on my energies. (Author’s emphasis)

The concepts of nonmonetary and monetary lead me to a discussion of intrinsic vs. extrinsic motivation as it relates to the practice of medicine. Let’s define intrinsic motivation as an activity an individual does simply because they enjoy it or derive some level of personal gratification simply because they are able to do it… enjoyment of the work or an activity for its own sake. On the other hand, extrinsic motivation is essentially induced behavior: “If you do this, you’ll get that.” The idea of extrinsic motivation is, that, if a positive reward is given out for a task, it will lead one to continue wanting to do the task, to keep getting the reward. It is, in essence, a method of controlling behavior, and is, in reality, no different than the promise of punishment if one does not do something.⁴ In other words, the promise of a reward could be reworded to say, “If you don’t do that, you won’t get this,” which is, in essence, a form a punishment. Think of pay-for-performance—is this not the perfect example of extrinsic motivation?

Up next in the Leadership Series: A Chasm of Disconnect: Community, Motivation, and the Patient: Part Two

All content from Civil Leadership, by Michael S. Woods. © 2007. All rights reserved.

References

1. Lee. F: If Disney Ran Your Hospital. Bozeman, MT: Second River Healthcare Press, 2004.
2. Hock, D: Birth of the chaordic age. San Francisco: Berrett-Koehler Publishers, 1999.
3. Hilfiker, D. Healing the wounds. New York, Pantheon Books, 1985.
4. Kohn, A: Punished by Rewards. New York: Houghton Mifflin, 1993.

Ineffective Communication: The Major Risk In Health Care

In their paper “Five System Barriers to Achieving Ultrasafe Health Care,” Amalberti, Auroy, Berwick, and Barach describe three risks that combine in health care to generate risk in terms of patient safety: (1) that of the disease itself, (2) that entailed by the medical decision, and (3) that of implementing the selected therapy.⁴ They state, “These three risks generally do not move in the same direction. This complexity makes error prevention harder to predict and grasp.”^{4(p. 761)} I believe defining these three risks is the most important information in this excellent paper, because it highlights the complexity of health care risk and patient safety.*

The Amalberti et al. paper stimulated me to think about these three areas of safety risk. After a short while, I realized that safety in health care is much more complicated than even the Amalberti et al. paper proposes. The paradigm suggested is only partly correct, as is any paradigm, including that presented here. Hopefully, what I propose will stimulate someone else to continue to round out and refine the paradigm in the patient safety and medical liability puzzle.

I agree with the three sources of patient safety risk that Amalberti et al. note. I would like to add important elements to their model—elements critical to approaching the issues in patient safety and malpractice risk with eyes wide open.

There are at least two other noteworthy sources of risk to be added to this model: (1) the individual patient’s physiologic response to treatment, and (2) communication. While work on predicting the physiologic response is ongoing, it is still early and remains, in many cases, theoretical. An example of this would be new tests to define how an individual might metabolize a certain drug on the basis of his or her hepatic enzyme profile. If the individual has hepatic subenzyme 2D6 in the P450 system, he or she would be prescribed Drug A. If the individual doesn’t have 2D6, he or she would be prescribed Drug B.

Communication is a different story. As already noted, ineffective communication is widely acknowledged to be a root cause of most patient safety issues and medical malpractice claims. In addition, the further one progresses along the path of the original three sources of risk, the greater the number of “players,” or individuals involved in the delivery of any given intervention or treatment. (See Table 5-1.) The greater the number of players, the more communication becomes critical, albeit complex, and the greater the likelihood for communication gaffes between the players that can lead to safety problems.

 

Communication complexity increases as more players become involved.

Table 5-1. Progression of Communication Risk

With each step along the diagnosis and treatment spectrum, the number of players increases. Communication “risk” increases as the number of players increases as a result of the potential for miscommunications or misunderstandings.

Effective communication requires a speaker to communicate effectively and clearly to a listener—the person to whom he or she is speaking. The listener must comprehend what is attempted to be communicated. Speaking effectively and accurately and comprehending what is heard is influenced by at least six different things I call communication variables: (1) ethnic variables, (2) socioeconomic variables, (3) literacy variables, (4) sex (gender) variables, (5) personality variables, and (6) time variables. Each of these Variables can affect each of the other Variables for every party involved in the communication process. This equates to at least 36 variables that can affect communication outcome between two individuals. Adding a third individual increases the number of variables in the communication equation to 216. A fourth makes it 1,296! In other words, the effectiveness of communication is determined by two or more individuals (and usually, in health care, many more than two) and a complex interplay of these six variables within and between each player. The potential for misunderstandings as players are added to the field is staggering. From this perspective, it doesn’t seem quite as puzzling why communication plays such a major role in patient safety and malpractice.

Let me give an example. I am an Anglo-American male physician. In the hospital where I work, there are nurses from India, all female. We have many patients who are Native American and Latino. Imagine me, a Western-trained physician, interacting with a nurse from India and giving her an order that is incorrect. The Indian nurse knows the order is wrong, but her ethnic background is one of non-confrontation. Imagine this same nurse working with Latino patients who might have very different ethnic traditions than I, the Anglo, or she, the Indian. Even if we leave the language barrier out of the discussion, with all the colloquialisms that can confuse, is it really all that hard to image a medical error occurring in this environment? If you are honest with yourself, the answer should be “no.”

Not only is communication important, but the effectiveness of an individual caregiver’s communication is probably more variable than diagnostic or treatment options in terms of the number of variables that can affect outcome and safety.

 The effectiveness of an individual caregiver’s communication is probably more variable than diagnostic or treatment options in terms of the number of variables that can affect outcome and safety.

If we can sort out, understand, and be aware of the differences among ourselves, our coworkers, and our patients—differences in literacy, socioeconomics, ethnicity, gender, behavior, and time—we will be in a better position as providers to find common ground and the mutual respect required for clear communication. The result will be safer health care, improved outcomes, and a profession whose integrity has been restored because of the patient-centered focus it brings.

Up next in the Communication Series: Ethnicity

All content from In A Blink, by Michael S. Woods. © 2007. All rights reserved.

References

4.  Amalberti R., et al.: Five system barriers to achieving ultrasafe health care. Ann Intern Med 142:756–764, May 3, 2005.

The DUN Factor

The fact is, life is DUN: Dynamic, unpredictable, and nonlinear.

—Michael S. Woods, M.D.

A Different Kind of Data

The book from which this is taken is about data. But a word of caution is in order because it’s not the kind of data providers are used to using. The medical profession is legendary for applying linear logic and scientific method to any problem it faces, whether it is a disease or the current center of attention in health care, patient safety. The linear-logical approach has resulted in great successes, and medicine today has conquered things our medical forefathers would have considered science fiction. But this approach has also resulted in a hammer mentality: Every new problem looks like a nail. It is the almost religious belief that everything and anything we encounter in health care can be solved if we apply enough brain power and logic, and keep the heat on just a little longer, until the problem is distilled down to its component parts—discrete, definable, predictable pieces.

Unfortunately, in its single-minded quest to define things to the “nth degree,” the medical profession often fails to learn from other professions. Philip W. Anderson, a 1977 Nobel Prize winner in physics, a stringent science with a legendary propensity for breaking things down into their elemental components, noted:

The ability to reduce everything to simple fundamental laws does not imply the ability to start from those laws and reconstruct the universe. In fact, the more the elementary particle physicists tell us about the nature of the fundamental laws, the less relevance they seem to have to the very real problems of the rest of science, much less society.^{1(p. 81)}

As medicine understands more and more about the human body and its ailments, and seeks to define every aspect of care in terms of process to enhance safety, it seems we drift further away from humanism and the very real needs of the individuals we treat. Providers must stop focusing exclusively on the sterile, linear-reductionist perspective and learn how to make sound scientific judgments while remaining sensitive to patients’ emotional needs, and being perceptive enough to distinguish important nuances in the complex provider-patient relationship.

Health care futurist and lecturer Leland R. Kaiser, Ph.D., explains this professional tendency toward unidimensionalism in health care this way:

General systems theory really has three dimensions and one dimension is the way you think. And we call that conceptual. If I see you, I will see you as a system. I will see you as a physical body. I will see you as an emotional body. I will see you as a mental body. I’ll see you as a spiritual body. I will see you as a multidimensional person.

The biggest problem in medicine is to assume people are their bodies. We’ve been stuck with that one for a long time. You are not a body. You have one. Thinking you are your body is like thinking you are your automobile. It’s a vehicle. And yet when I look at medical care, it’s mostly body oriented. In spite of the evidence, almost overwhelming evidence, that a good deal of disease occurs at the other three levels [emotional, mental, spiritual], we still focus on bodies.²

The patient safety movement is an incredibly important effort, yet it sits precariously poised at the edge of the same logic-driven chasm as the rest of medicine, obsessed by a nearly exclusive focus on defining processes as the key to enhancing safety. The movement is on the brink of making the same mistakes as the medical malpractice insurance industry, and the medical profession itself, by ignoring incredibly important aspects of the human relationship as related to patient safety and issues that create liability. In its current state, the patient safety movement is in danger of over-promising and under-delivering unless it includes a focus on the relationship between the caregiver and the patient as a core and critical piece of the puzzle.

Enter The DUN Factor. DUN is my mnemonic for “Dynamic, Unpredictable, and Nonlinear,” and it reflects how life really “is.” In brief, Life is DUN. The DUN Factor is responsible for many patient safety breaches, as well as accounting for a significant amount of the medical malpractice environment. The DUN Factor forces us to understand and embrace the multidimensional aspect of life and begin our journey back to a holistic (if not wholistic!) approach to the human beings that we call patients.

Perhaps nowhere in our daily experience is the DUN Factor more evident than in the communication between two (or more) people. Who would argue that conversation between two or more individuals is not dynamic, often unpredictable and nonlinear, especially in emotionally charged situations, as is often the case in health care. Think about discussions in which politics or religion is the topic. Have you ever used a logical argument to reason with an individual who is upset or emotional about something, only to have it backfire? Regardless of the intelligence and logic you use, and no matter how convincing it may be to a third-party observer, it can inflame one who is not in the same place as you emotionally. And whether you appreciate it or not, the reaction itself is data. If you missed or miss-read the data, you can jeopardize the relationship.

The most dynamic, unpredictable, and non-linear aspect of our lives is communication.

Stephen Covey, the personal leadership guru and author of The Seven Habits of Highly Effective People, notes communication is not something that can be applied efficiently. Communication must be effective. He explains that, with people, “slow is fast, and fast is slow.” In other words, effective communication, which may require more upfront time between people, ultimately achieves clarity of purpose and enhanced understanding, therefore resulting in fewer misunderstandings. Ineffective communication, often the result of an attempt to communicate efficiently (that is, quickly), is unclear, can result in partial or poor understanding, if not overt confusion, and can lead to mistakes. Ineffective communication causes delays, as questions are often needed to gain a clear understanding, and can slow implementation of instructions. It is, therefore, actually inefficient. Ineffective, hurried communication can also make people angry, especially in emotionally charged situations, as health care often is.

Health Care Delivery and the DUN Factor

For all the analogies made between the airline industry and health care, the one comparison that seems trivialized, if not ignored, is the fact that, in general, well-maintained machines are always more predictable than living organisms. Short of mechanical failure (which of course can be caused by a human error, such as lack of maintenance), aircraft act predictably. If the pilot makes a decision and acts on it, the aircraft responds in the same way, time and time again. This is clearly reflected in the airline industry’s remarkable safety record since the advent of crew resource management.

This type of predictability does not exist in the realm of the living organism, despite medicine’s attempt to define such predictability with our linear-logical thinking. For any single intervention carried out with perfect efficiency, accuracy, and technical expertise, there can be multiple outcomes, including serious side effects, rampant infection, and even death. Consider the anaphylactic reaction that results in the death of an individual who has just started a medication that, while clearly indicated and supported by evidence-based medicine, was new to the person. This same medication is used safely in tens, hundreds of thousands, or even millions of people daily. Enter the DUN Factor.

I had a fascinating and educational conversation regarding the airline industry/health care analogy with Bill Hamman from Western Michigan University’s College of Aviation.³ I learned some great stuff. First, Bill is very smart. Second, I reluctantly shared my thinking from the two paragraphs preceding this one, thinking he would probably tell me I was out to lunch. To my dismay, he agreed and further helped me understand the important differences between the aviation industry and health care. (This conversation happened before Mr. Hamman was discredited. Regardless, his analogies remain remarkably accurate.)

Bill said he clearly sees three critical differences between health care and aviation, and they each make creation of a safe health care system much more difficult than making air travel safe.

The first difference is the team. In an aircraft, the team is static and limited. There are only a handful of individuals on the flight, and they don’t change during the flight. The patient represents a flight episode or “sortie” in health care.* The health care team is often poorly defined, if it is defined at all. The health care team is also fluid, in that the team members caring for the patient change from shift to shift. Restated, in health care, we change not only the pilot and copilot in midflight, but the attendants too. All of this makes communication more difficult and error prone. This also highlights one reason why The Joint Commission is so focused on hand-off communications between providers.

The second difference Bill has identified is that of leadership. On a 757 there is no doubt who the leader is: the captain. In health care, leadership is poorly defined and ever changing. If the attending physician is on the floor, he or she is the leader. If the attending is not on the floor, the resident is the leader. In private practice, the physician group may clearly understand who is responsible for the patient, but might not have communicated it to the nurse caring for the patient. Who does she call? And in the event she is unable to get in touch with a provider, who is accountable?

The third difference is that there is a common bond created among aviation workers in the use of external resources. Flight crews are intimately connected to the ground maintenance crew, air traffic control, and other systems. If they encounter trouble in flight, such as bad weather, they are rerouted as appropriate, disparate units working in harmony to avert a potential crisis. No such common bond is seen in health care or between health care providers. Providers act independently of the nurses and other support personnel. Cooperation often arises only out of the necessity that accompanies a crisis that has already occurred.

Up next in the Communication Series: Ineffective Communication: The Major Risk Factor in Health Care

All content from In A Blink, by Michael S. Woods. © 2007. All rights reserved.

References

1. Waldrop M.M.: Complexity: The Emerging Science at the Edge of Order and Chaos. New York: Simon & Schuster, 1992.
2. Kaiser L.R.: In The Future of Healthcare. American College of Physician Executives InterAct course. 2006.
3. Personal communication between the author and William Hamman, Oakbrook Terrace, IL, Oct. 5, 2006.

The Decline of Effective Communication and Patient-Centered Medicine

So the problem with medical specialties is finding you get so specialized, you understand so well, in detail, such a small part of it [the specialty], you forget there’s a patient there.

—Leland Kaiser, Ph.D., from his lecture to the American College of Physicians, on ACP’s CD–based course, Health Care of the Future, May 2002.

The critical need for improving communication skills in health care has seemed obvious to me for more than two decades. The need for a concerted effort by the profession to focus on enhancing communication skills was illustrated clearly by a focus group with practicing physicians I held in Chicago in summer 2004. The intent of the focus group was to identify physician attitudes regarding the importance of communication, their willingness to use patient experience surveys in their practices, and their interest in improving their interpersonal skills.

One question asked of the group was, “Do you believe that patient-physician communication is important?” One hundred percent of the participants enthusiastically responded, “Yes! Absolutely!”

The following question was, “Would you participate in a structured program to help you improve your communication skills?” One hundred percent of the participants, with equal vigor, or perhaps venom, shouted, “No! Absolutely not!” The predominant attitude was summed up by one of the participants when he said, “I think I am the best communicator I know.” It is clearly a case of not knowing what we do not know.

I began wondering why, in a profession that screams for individuals with superlative communication skills, we have evolved into a group that is perceived by our fellow providers (nursing, therapists, and other caregivers), and our customers—patients—as poor, or at least, ineffective communicators. The profession of medicine is increasingly viewed with skepticism, and the public’s respect for physicians has eroded significantly.

Jennifer James, an urban cultural anthropologist, notes in her book Thinking in the Future Tense that physicians are rarely leaders on major health care issues.¹ We have not been out in front on important health issues ranging from smoking, to equal rights, to domestic violence and child abuse, and most recently, patient safety—all things that have a dramatic, negative impact on health. As a result of this, respect for the profession has diminished. The extent of the medical profession’s activism during the medical malpractice crises is to shout loudly for someone else to solve our liability problems—that is, state or federal tort reform. Our inability to be effectively proactive for anything but lobbying against further cuts in reimbursement has slowly eroded respect for the profession.

A physician’s decision is no longer automatically accepted as the end-all, be-all, whether from patients, health insurers, managed care administrators, or the government. James claims that the result of this is tremendous loss of professional power and a profession that is deeply grieving for its loss of power and respect. Physicians, as a profession, are stuck in the anger stage of the grieving cycle.

James’s assessment is accurate. Physicians used to be among the nation’s most respected and admired professionals. Now they rank not just below nurses and pharmacists—people that they should be guiding and leading in health care—but they also rank below grade school teachers, military officers, clergy, and policemen.2,3 In a poll from December 2006, the public viewed nurses as the most honest and ethical professionals, while physicians were far behind in fourth place.4 Physicians’ loss of power and public respect seem to be marching on,
spiraling downward with no apparent end in sight.

I would suggest that the loss of respect in the public’s eye is related to a perfect storm of events beginning in the late 1960s, and that continues to engulf our profession in a vortex from which we cannot seem to escape. Ironically, the things that have resulted in a loss of professional power and prestige are the same things that have resulted in huge steps forward in our ability to treat disease:

• Advances in pharmaceutical technology (drug discovery)
• Advances in medical/surgical devices
• The explosion and rapid dissemination of medical information

The number of new drugs approved by the Food and Drug Administration has, on average, doubled annually since the early 1980s, from 19 to 311 new drugs approved in 1999.^5,6 With the availability of newer, more effective drugs and technology, providers have had more to learn in medical, nursing, and pharmacy schools as well as residency, with practicing physicians constantly scrambling to keep up. As with all things, there are unintended consequences that cannot be predicted when something new comes along.

“So what?” you might ask. The “So what?” is that concomitant with the added responsibility to learn ever more facts has come a decrease in physicians’ ability to communicate effectively with their primary customer, the patient, and the individuals charged to help them deliver care. Because increasingly more time has been needed to focus on learning how to be a technically competent individual, less time has been available for our young health care professionals to learn how to effectively interact and communicate with the very people they will work with and treat. The result? Three major medical malpractice crises since the 1970s—in 1975, 1984–1986, and 2001–2004, with many major insurers leaving the business, including Argonaut, Travelers, Hartford, and St. Paul.7 Note that the first crisis in 1974 was one year long. The crisis in the 1980s was two years long, and in 2001, four years long. The length of the crises appears to be doubling with each occurrence.

The other unintended consequences of the assault on effective communication include an abysmal record of patient safety, a patient population with awful customer satisfaction and distrust of those treating them, and an angry, grieving profession that fails to take accountability for problems that only it can solve. These relationships are summarized in Table 4-1.

Positive and not-so-positive consequences.

Data support this hypothesis. Figure 4-1 illustrates the ascending parallels between malpractice tort costs, pharmaceutical and device approvals, the number of medical journals and MedLine citations, and textbook pages from a major medical and surgical text beginning in 1960. I can safely assert that major patient safety gaffes would also parallel these variables, had data existed. Consider that the number of biomedical journals doubles approximately every 19 years.8 Thirty years ago it was estimated that the “core information” for the internal medical specialty was one million facts—and medicine subspecialties had two million! If facts parallel journal proliferation, medical residents are now confronted with about three million facts to learn and subspecialists with six million! There must be purple smoke roiling out of their ears, they are so overloaded with minutiae. With so many facts to learn, and the emphasis on technical competence, when does a student, resident, or practicing physician have time to pay attention to such mundane things as interpersonal communication skills? I have taken the liberty, claiming editorial license, of drawing a line in Figure 4-1 representative of the profession’s communication competence, which understandably is headed in the wrong direction…and with the HIT being added to the mix, it can only continue to be challenging.

Information and technology exploded to the detriment of communication.

Up next in the Communication Series: The DUN Factor – A different kind of data.

All content from In A Blink, by Michael S. Woods. © 2007. All rights reserved.

References

1. James J.: Thinking in the Future Tense. Northampton, MA: Free Press, 1996.
2. Lazarus A.: Putting Trust Back in Health Care. Unique Opportunities: The Physician’s Resource. Jul.–Aug. 2005. http://www.uoworks.com/articles/remarks.trust.html (accessed Mar. 28, 2007).
3. Waters S.B.: How is your reputation faring? Surveys indicate both good and bad news for CPAs— From the CEO. California CPA, May 2003.
4. Quan K: Nurses Are Most Honest and Ethical. Suite 101. Feb. 1, 2007. http://public-healthcare-issues.suite101.com/article.cfm/nurses_are_most_honest_and_ethical (accessed Apr. 10, 2007).
5. The Henry J. Kaiser Family Foundation, 2000.
6. U.S. Food and Drug Administration, 2000.
7. Personal telephone communication between the author and Sarah M. Dore, CPCU, Sep. 25, 2006.
8. Wyatt J.: Use and sources of medical knowledge. Lancet 338:1368–1373, Nov. 30, 1991.
9. Accreditation Council for Graduate Medical Education: ACGME Outcome Project: General Competencies, Feb. 1999. http://www.acgme.org/outcome/comp/compFull.asp#4 (accessed Mar. 29, 2007).

Communication Matters (A lot!)

Most ailing organizations have developed a functional blindness to their own defects. They are not suffering because they cannot resolve their problems, but because they cannot see their problems.

—John Gardner, in Covey S.R.: The 8th Habit: From Effectiveness to Greatness. New York: Free Press, 2004, p. 19.

The Undeniable Truth

It seems as if John Gardner was thinking of the health care industry when he wrote the quote above. This entire book is, in fact, about drawing attention to the pernicious and systemically ignored problem of inadequate, sometimes overtly poor, communication skills of health care providers.

This somewhat depressing assessment is based on personal experience, observation, and two undeniable bits of hard data: There is near universal agreement among risk managers in the United States, Canada, the United Kingdom, and Western Europe that up to 80% of malpractice claims are attributed to failures in communication and/or a lack of interpersonal skills, usually by a physician. Reams of data support this statement. Hickson concluded that physicians with the highest risk for lawsuits were poor listeners, often failed to return phone calls, and were rude and disrespectful to patients—all communication behaviors.1 Other research has found a statistically significantly higher risk of claims in surgeons who tended to be conflict avoidant and had poorer team leadership skills, both reflective of ineffective communication skills.2 Even The Joint Commission has noted, “Physicians are most often sued, not for bad care, but inept communication.”3

These same “inept communication practices” cited by The Joint Commission result in the majority of patient safety issues. In 1996 The Joint Commission identified communication as one of the top five issues contributing to the generation of medical errors. The Joint Commission has collected sentinel event statistics since 1995. Through 2006, 3,835 events have been reported, of which 73% resulted in patient death and 10% in loss of function. The most common root cause of a sentinel event is communication failures, being the primary driver in more than 65% of cases.4 Of 12 root causes identified, I would suggest that communication plays an indirect role in an additional 6: orientation/training (Are people clear on what is to be done?); availability of information (Are people getting the information they need?); procedural compliance (Again, is it clear what is to be done?); leadership (Are leaders—that is, providers—communicating clearly what is to be expected?); continuum of care (Is the communication clear when a patient is handed over to a new provider?) and care planning (Is the plan being clarified and are all caregivers being heard?)

The messages that have accumulated over decades are screaming at us from our own literature, yet the issue of effective communication continues to be ineffectively addressed and poorly understood. It is time we commit to the obvious fact that we, as a profession, must not only turn out providers who are technically competent, but who also appreciate the need for and are capable of effective, empathetic, respectful communication.*

 Safety in Complex Environments: Communication First

In their book Managing the Unexpected, Weick and Sutcliffe use nuclear aircraft carriers as an example of a high-reliability organization (HRO). They weave a compelling story of the dangers present on an aircraft carrier and how safety is achieved on these complex, floating mini-cities:

The elements that produce safety on a carrier are quite straightforward. They include communication, respectful interaction, and competence in filling one’s role and performing the tasks associated with that role.5(p. 32)

They go on to note that HROs “. . . are clear that you can’t ‘fix’ the safety problem, store up safety, and then move on to something else.”5(p. 32)

I found it interesting that communication and respectful interaction, not competence or process definition, are listed first. Although clearly important, competence and process alone are impotent without effective communication and respectful interaction.

 A Deeper Understanding: Team-Based Care, Communication, and Patient Safety

Of all the ways by which people are led to seek rewards, I believe the most destructive possible arrangement is to limit the number that are available. To do so is to replace the possibility that people will try to assist each other with the near certainty that they will try to defeat each other. But whether it is simply permitted by a standard individual incentive system or actually required by a race for rewards, contests are destructive for several reasons beyond the fact that they preclude the sort of teamwork that leads to success.

—Alfie Kohn, in Kohn A.: Punished by Rewards: The Trouble
with Gold Stars, Incentive Plans, As, Praise, and Other Bribes.
New York: Houghton Mifflin Co, 1999, p. 55.

It is no longer acceptable in today’s complex, interdependent health care environment to be a lone ranger, continuing to practice within the cottage industry paradigm. Team-based care is clearly superior to the old way, but there are huge barriers to the better path. In this section’s introductory passage from Kohn’s book highlighting competition in education, who would argue that physicians are trained in a manner that engenders a team-based approach? From start to finish, medical students compete against each other—for acceptance into the best schools, class ranking, desirable residency slots, and so on. Residents then compete against each other for Fellowships. And on it goes in a never-ending cycle of win-win competition. The system is designed to winnow out the weakest at each step. As a result, it teaches physicians that it’s better to win than to lose, creating an approach to problems that results in valuing competition over cooperation. Yet cooperation is exactly what is required for teamwork and team-based health care.

Despite the physician being inadequately prepared to lead a team, few individuals who know anything about health care would disagree that the physician is viewed by most to be the leader of the health care team. Unfortunately, many rightfully debate if physicians are effective in this role. Grumbach and Bodenheimer note there are two key questions for teams6:

1. Who is on the team?

2. How do team members work together?

Ask yourself these two questions and think of your office or unit. You will find they are not simple questions to answer, and you will, most likely, not be proud of your answer.

Simply because people work in the same office or on the same unit doesn’t mean they function as a team. Grumbach and Bodenheimer point out that a football team composed of the right number and type of players will have little success if they don’t have a playbook, practice, and develop a game plan. Likewise, a group of health care providers thrown together into a clinic or a care unit can be called a team, but this often does not demonstrate teamwork. A team is a group with a specific task or tasks, the accomplishment of which requires the interdependent and collaborative efforts of its members.7

The authors who constructed this definition illustrate the difference between a mere grouping of people and a team:

It is naive to bring together a highly diverse group of people and expect that, by calling them a team, they will in fact behave as a team. It is ironic indeed to realize that a football team spends 40 hours a week practicing teamwork for the two hours on Sunday afternoon when their teamwork really counts. Teams in organizations seldom spend two hours per year practicing when their ability to function as a team counts 40 hours per week.7( p. 1247)

Add to these observations the additional obstacle of interdisciplinary territoriality and the inevitable inertia of large organizations, and it is a wonder there is ever a coordinated effort! But imagine what an incredible effect even two hours of teamwork practice per week would mean to care quality and safety!

Unfortunately, the fact that teamwork in health care is rarely, if ever, practiced in the same manner as a football or baseball team emphasizes that clear, effective communication is not just important, it is critical. (Of course, there are pockets in the healthcare system where this is changing.)

Health care is not team based in most organizations. In hospital units, individuals (who would otherwise be a team member on a multidisciplinary care team) see the patient based on their schedule, or they are invisible, working like a wizard behind the scenes. Physicians often do not start their rounds in the same place or time each day, making it virtually impossible for consistent nursing participation. Physicians often do not call the nurse caring for the patient to make rounds, a simple practice that would enhance interdisciplinary understanding and care integration. If a consult with physical therapy or nutrition is needed, it is a physician who writes the order to obtain the consult. The message is relayed to the consulting party through a “middle man,” (that is, the ward clerk), who may not understand why the consult is needed. This is not only time-consuming and inefficient, because the consultant must review the chart and ask questions, many of which are redundant to what would have been answered in a team effort, but it most assuredly increases the risk of misunderstandings, miscommunications, and errors. Repetitive, redundant questioning of patients and families leaves the impression (probably an accurate one) that team members are not communicating effectively, negatively affecting the patient’s and family’s confidence in the care they receive.

Despite the visible lack of teamwork in most health care organizations, the number of publications on the value of team-based care has increased in frequency since the year 2000. Here are a few summary bullet points from the medical literature:

• Team-oriented care in the intensive care unit is associated with better technical quality of care, lower length of stay, and improved relationships with families.8
• Teamwork is associated with better processes of care, better continuity of care, better access to care, and patient satisfaction in patients with diabetes.9
• “Healthy communication” between caregivers resulted in better outcomes of patient-perceived quality and patient satisfaction.10
• A research team at Kaiser in Georgia found that a “collaborative clinical culture” had superior patient outcomes, including patient satisfaction.11

If the above bullet points were trumpeting the success of a new evidence-based treatment for diabetes, it would change the practice of clinicians tomorrow. But changing clinical practice is easier than changing communication style and one’s daily routine; to change one’s clinical practice, one merely needs to believe a treatment is better, understand it, and implement it. To change one’s communication practice, there must be a commitment to improve, individuals who can help with the change effort, planning around other people’s schedules, and education regarding team leadership—a much taller order.

As long as decisions must be made by a human in situations in which there are multiple possible answers (for example, a diagnosis) to any one problem (as there almost always is), and that decision results in the need to make additional decisions (for example, a treatment), also with multiple possible solutions, and such solutions are to be applied to a living, breathing being who has virtually limitless, unpredictable physiologic responses, the possibility for unexpected outcomes, even with perfect adherence to process and evidence-based medicine, will always exist. This is only compounded when imple­ment­ing any of the many potential solutions that rely on the effectiveness of communication between two or more individuals, as is always the case in health care.

Communication complexity increases as one moves from presentation, to diagnosis, to treatment, and more players become involved.

Clearly, training our health care personnel in teamwork is a worthy investment in time and energy. However, before effective team-based care can be delivered, providers must understand the importance of effective communication. What’s more, providers must be trained to communicate effectively, treat their team members with respect, and understand how to create a collaborative environment. Resistance is assured, and nonparticipation is often justified by saying, “I don’t have time.” Richard Bach, the author of Jonathan Livingston Seagull and Illusions: The Adventures of a Reluctant Messiah, wrote in the latter “The easiest way to avoid responsibility is to say ‘I have responsibilities.’” We must assume responsibility and make the time, because our patients’ safety and outcomes depend on it.

Up next in the Communication Series: The Decline of Effective Communication and Patient-Centered Medicine

All content from In A Blink, by Michael S. Woods. © 2007. All rights reserved.

References

1. Hickson G.B., et al.: Patient complaints and malpractice risk. JAMA 287:2951–2957, Jun. 12, 2002.
2. The use of a standardized personality assessment in determining near-term medical malpractice risk. Data on File, Michael S. Woods.
3. Joint Commission International Center for Patient Safety, Communication Expert Panel Syllabus, Oct. 5, 2006.
4. http://www.jointcommission.org/NR/rdonlyres/FA465646-5F5F-4543-AC8F-E8AF6571E372/
   0/root_cause_se.jpg (accessed Aug. 8, 2007).
5. Weick K., Sutcliffe K.: Managing the Unexpected. San Francisco: Jossey-Bass, 2001.
6. Grumbach K., Bodenheimer T.: Can health care teams improve primary care practice? JAMA 291:1246–1251, Mar. 10, 2004.
7. Wise B.J., et al.: Making Health Teams Work. Cambridge, MA: Ballinger Publishing Co., 1974.
8. Shortell S.M., et al.: The performance of intensive care units: Does good management make a difference? Med Care 32:508–525, May 1994.
9. Campbell S.M., et al.: Identifying predictors of high quality care in English general practice: observational study. BMJ 323:1–6, Oct. 6, 2001.
10. Goni S.: An analysis of the effectiveness of Spanish primary care teams. Health Policy 48:107–117, Aug. 1999.
11. Roblin D.W., et al.: Collaborative clinical culture and primary care outcomes. Paper presented at Academy for Health Services Research and Quality meeting, Washington, DC, Jun. 23–25, 2002.

Why Relationship-based Civil Leadership Is Good Business Strategy

For those who remain skeptical of the value of leadership training in health care, there are clear, evidence-based examples of leadership’s value. Undeniable statistical confirmation of leadership’s value came in late 2001. David Maister published Practice What You Preach, a book based upon a prospective, longitudinal study of the major organizational influences that determine financial performance. Maister’s hypothesis was that when leaders are effective as individuals and energize and excite their employees, employees will better serve customers. As a result of excellent service, the client will be more loyal, and loyalty produces more revenue for the organization.

He tested this hypothesis in 139 offices in 15 countries in 15 different industries. This is not exactly a small sample size, and absolutely meets the definition of “evidence-based” we are so fond of evoking in health care. Maister examined four objective measures of organizational financial performance, obtained from each of the offices, and included

1. Two-year percentage growth in profits
2. Two-year percentage growth in revenues
3. Profit margin
4. Profit per employee

The results were analyzed using stepwise regression to demonstrate what factors move together (i.e. are related), and structural equation modeling, predicting what causes what—in other words, causation—when there are multiple factors involved. Maister’s statistical analysis was focused on defining what factors actually caused profitability. From this, Maister constructed the Causal Model of organizational financial performance (see Figure below. Source: Maister, D.: Practice What You Preach. New York: Free Press, 2001. Reprinted with permission of author.)

In its simplest form, the causal model statistically verifies the following predictors of financial performance:

1. Financial performance is caused by quality and client relationships
2. Quality and client relationships are caused by employee satisfaction
3. Employee satisfaction is caused by high standards, coaching, and empowerment
4. High standards are caused by fair compensation, commitment, enthusiasm and respect
5. Coaching is caused by long-term orientation, commitment, enthusiasm, and respect

The nine variables in this model (each box in the diagram) reflect over 50% of all variation in profit performance of an organization. These results apply across all industries and cultures studied. Adapting these statistically confirmed conclusions to health care gives us the following extrapolations:

1. Financial performance is caused by quality service, care, honesty, empathy, and patient relationships, i.e. relationship-based civil leadership
2. Quality service, care, and patient relationships are caused by health care employee/provider satisfaction
3. Employee/provider satisfaction is caused by high standards, coaching, and empowerment of their employees
4. High standards of providers are caused by fair compensation, commitment, enthusiasm and respect of fellow providers and employees
5. Provider coaching is caused by long-term orientation, commitment, enthusiasm, and respect

These five causal relationships are the very embodiment of civility-driven, relationship-based health care.

Maister’s model statistically proves that a single-point improvement in the measure “Client satisfaction is a top priority at our firm” (on a six-point scale), results in a 104% increase in profitability! For illustration, imagine an organization scores a 3 out of 6 on a patient satisfaction survey in year one. In Year Two they make improvements that result in a score of 4 out of 6 at the end of year two. They would realize a 104% increase in profitability during this time.

If this were a study confirming a new miracle oral medication that permanently cured diabetes, every CEO in every healthcare organization in the country would mandate the treatment… and every provider would change their practice patterns today, based upon the strength of the data. Why can’t we in health care change our organizations based on this incredible data set? Why don’t we start today? Relationship-based care is the key, where the basis of relationship-based care is civil leadership. In order to establish effective teams who focus on relationship-based care, a culture of civil leadership must be established.

Health care is an industry dependent upon effective relationships. Civility, including effective communication and interpersonal skills, are imperative, and form the base of Maister’s causal model pyramid, leading to profitability. If providers and their organizations focus on quality care (the service component), client relationships (i.e. the patient), and employee satisfaction, all driven by the provider’s civil leadership, profitability will increase. Simply put, by energizing the organization around doing the right thing, back-end profitability takes care of itself.

Up next in the Communication Series: The Provider-Patient-Organization (PPO) Principle

All content from Civil Leadership, by Michael S. Woods. © 2007. All rights reserved.

The Bottom Line Cost of Losing Employees

Every provider interacts with other staff and patients. It is crucial they treat both with civility—with respect, empathy, and compassion—to achieve the critical strategic goal of retaining valuable employees and patients. In other words, providing civility-driven, relationship-based health care. Doing so will directly affect the practice’s success. The physician who enables employee satisfaction and motivation will reduce employee stress and turnover within the organization. And reduced turnover decreases the amount of time and money spent trying to attract and retrain replacements. Further, reducing stress in health care employees is statistically correlated to reducing organizational malpractice risk.¹⁴

Health care organizations—and their providers—often don’t appreciate the huge expense associated with losing an employee. How expensive is employee turnover? Recruitment and retraining costs to replace a single departing employee ranges from 1.5 to 2 times the departing employee’s annual salary.¹⁵ Children’s Hospital of Pittsburgh reported an average cost of $17,486 to replace a single staff member in their poison control center.¹⁶ This pales in comparison to what it costs to replace an unhappy physician who leaves a health care organization. Recruitment and replacement costs for a single primary care physician is $236,383 for a general/family practice physician, $245,128 for a general internist, and $264,383 for a pediatrician. The total turnover costs for the 533 physicians studied in these groups tracked over a 5-year period was $69 million.¹⁷

In the June 2002 American Journal of Nursing, VHA West health system reported that of 1200 nurses, administrators, and physicians surveyed, 93% had witnessed disruptive physician behavior.¹⁸ Nearly 1/3rd knew of at least one nurse who had quit their job because of a physician’s behavior. Such unprofessional behavior should not be tolerated in any organization. But it also costs money: some estimate that a single disruptive physician can cost an organization $150,000 per year in employee turnover. This is lost income —money physicians and their organizations never recover or realize as income.

“Turnover in the health care industry is a major detriment to the delivery of cost-efficient, quality care,” according to Kiel.^{19 (p. 12)} Satisfied employees, on the other hand, especially nurses, increase patient satisfaction and improve patient outcomes resulting in retained or increased dollars for the practice or organization.

Lest one scoff at the importance of ensuring employee satisfaction in health care as a strategic focus for organizational success, consider this: the current and future prosperity of a health care organization is contingent on its ability to find, train, and retain a high-quality staff, especially nurses.²⁰ With nearly 60% of the current nursing force over the age of 40 years, combined with the fact that the number of RNs under the age of 30 years has fallen nearly 40%, medical offices and hospitals will have to scramble for a limited talent pool, assuming they aren’t already.²¹ It stands to reason that the total number of RNs will shrink even further as substantial portions of the “baby-boomer” nurses retire. Retention of talented non-physician health care employees should be a primary strategic goal of medical organizations and will determine whether they survive, much less compete, in the next two decades. Provider behavior and leadership will have a direct effect on the success of this strategy.

In a 2008 Wall Street Journal article titled “Keeping Workers Earns a Bonus In Some Offices,” Cari Tuna noted that some firms view employee retention as such an important key to organizational success that managers are incentivized by bonuses to reduce employee turnover.²² Roger S. Penske of Penske Automotive Group was paid a $240,000 bonus for reducing attrition to 30.8%—a mere 0.4% improvement over the year previous! While this may seem excessive, it highlights the importance organizations are placing on retention and the expense related to employee churn and organizational profitability. Imagine what incentivizing a nursing manager or physician unit director, based upon unit retention… or a whole unit whose bonus is tied to it, would mean for turnover!

Up next in the Communication Series: Why Relationship-based Civil Leadership Is Good Business Strategy

All content from Civil Leadership, by Michael S. Woods. © 2007. All rights reserved.

Relationship-based Civil Leadership as a Health Care Business Strategy

Individuals may choose how they want to behave outside the work world, but businesses cannot afford to allow them this same choice in the workplace. The risks of taking a passive stance toward bad behavior are too high.

^— Giovinella Gonthier and Kevin Morrissey [In Gonthier, G and Morrissey K: Rude Awakenings: Overcoming the Civility Crisis in the Workplace. New York: Kaplan Trade Publishing, 2002, P 23]

 The Costs of Incivility (Bad Behavior)

All of the behaviors one associates with civility are critical to establishing effective working relationships with colleagues, patients, and health care staff.  Civil leadership—that is behavior—has a direct effect on health care outcome (compliance and safety), satisfaction and malpractice liability. (And keep in mind civility = kindness.) Behavior of individuals in leadership positions, whether a formal or informal position of leadership (power), has profound effects on employee satisfaction and retention, each of which can impact the organization’s bottom line. Consider these points, cutting across all groups of health care providers:

• Thirty percent of individuals in a survey of nurses, pharmacists and physicians knew of a nurse who left an organization because of disruptive physician behaviors.2
• Hostile treatment of graduate nurses by more senior nurses results in high staff turnover and the resultant poor communication results in poorer patient care.3
• Sixty percent of graduate nurses leave their first job within six months due to nurse-on-nurse violence… primarily verbal abuse from the individual’s preceptor. Twenty percent of new nurses leave the profession of nursing within three years to escape the hostility.3
• Disruptive behaviors of both nurses and physicians have a documented, significant negative effect on patient outcomes.4
• High-stress areas in medicine, like the operating room, are bastions of dysfunction that dramatically inhibit optimal team function and reduce the likelihood of an optimal outcome. “Disruptive behaviors increased levels of stress and frustration, which impaired concentration, impeded communication flow, and adversely affected staff relationships and team collaboration. These events were perceived to increase the likelihood of medical errors and adverse events and to compromise patient safety and quality of care.”5^{(p. 96)}

Companies of all flavors spend millions of dollars annually on leadership and communications training for their employees. This isn’t done out of the goodness of their hearts —they do it because such training has time and again demonstrated huge returns on investment for the company. Improvements realized from focused enhancement of leadership skills have a beneficial effect on the organization for years beyond the initial training, with sustained improvements in customer and employee loyalty and organizational profitability. Providers, their practices and health care organizations, can realize the same benefits of leadership and communications training, yet few health care organizations see the value proposition. Such expense is viewed as promoting “fluffy, touchy-feely” stuff, not the critical business proposition it really is. As Stephen Covey would say, they’re too busy driving to stop and get gas.

Relationship-based civil leadership, along with the attendant improved communication and interpersonal skills will increase health care revenue in five distinct, often under-appreciated areas:

One—Increased patient satisfaction and retention. Few physicians or health care organizations realize that attracting new patients costs six times as much as it does to keep the ones they have by ensuring they are satisfied. Further, a 5 % increase in customer retention translates into a 25 —125% increase in revenue!6

Two—Increased health care employee satisfaction and reduced turnover. I have consulted with health care organizations that have 18 —27% annual turnover of their health care staff, including nurses, resulting in millions of dollars of lost revenue annually. Providers do not appreciate that replacement and retraining costs for an employee is estimated to be between 70 —200% of the departing employee’s annual income.7 If a health care organization (or provider) decreases employee turnover, it enables them to keep more of what they collect.

Three—Reduced provider malpractice premiums. As a result of enhanced patient and employee satisfaction, and increased physician personal effectiveness, communication and interpersonal skills, malpractice liability will decrease. It wouldn’t be unreasonable for groups of physicians to ask for premium discounts if they demonstrate an overall improvement in civil leadership skills through a documented, standardized approach.

Behavior and liability are intimately linked.

Four—Reduced health care organizational liability. The same advice might be worth considering for health care organizations. A significant degree of stress within health care cultures is driven by provider behavior. In a study of 12,000 health care workers examining how job stress affected medical malpractice risks, organizations where workers had the greatest number of complaints concerning on-the-job stress had the highest rates of medical malpractice claims. Providers who create stress due to their behavior contribute to stress within an institution the organization, resulting in an unnecessary increase in organizational liability. 8,9,10,11

Five—Enhanced quality outcome and patient safety. Better communication and patient rapport translate into better treatment compliance with fewer complications and better health outcome.12, 13 In this day of pay-for-performance, quality equals dollars. In capitated environments, enhanced compliance results in fewer dollars being spent from the kitty—for the right reasons. You keep simply keep more of what you are paid.

Up next in the Communication Series: The Bottom Line Cost of Losing Employees

All content from Civil Leadership, by Michael S. Woods. © 2007. All rights reserved.

 

REFERENCES

1. Gonthier, G and Morrissey K: Rude Awakenings: Overcoming the Civility Crisis in the Workplace. New York: Kaplan Trade Publishing, 2002, P 23.
2. Rosenstein A., O’Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. Am J Nurs 2005;105:54–64.
3. World, H.: The violence that ends careers. http://news.nurse.com/apps/pbcs.dll/article?AID=200661222029&template=printart (accessed Jun. 27, 2009).
4. Rosenstein A., O’Daniel M.: Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. Am J Nurs 2005;105:54–64.
5. Rosenstein A.H., O’Daniel M.: Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006;203:96-105.
6. Sheth, J. Sisodia R.: Marketing productivity: issues and analysis J Bus Res, Volume 55, Issue 5, May 2002, pp. 349-362.
7. Kaye, B., Jordan-Evans, S.: Retention: Tag, you’re it! Training & Development, Apr. 1, 2000 p. 29.
8. Jones, J.W. et al: Stress and medical malpractice: Organizational risk assessment and intervention, Journal of Applied Psychology 73, 1988.
9. Caterinicchio R.P.: Testing plausible path models of interpersonal trust in
   patient-physician treatment relationships. Soc Sci Med. 1979;13A:81–99.
10. Thom D.H., et al.: Further validation and reliability testing of the Trust in Physician Scale. The Stanford Trust Study Physicians. Med Care. 1999 May;37(5):510–517.
11. Hall M.A., et al.: Measuring patients’ trust in their primary care providers. Med Care Res Rev. 2002 Sep;59(3):293–318.
12. Safran G.D.,et al.: Linking primary care performance to outcomes of care. Journal of Family Practice 1998;47:213–20.
13. Leach, M. J.: Rapport: A key to treatment success. Complementary Therapies in Clinical Practice, Vol. 11, No. 4. (2005), pp. 262-265.

Civility (and Kindness): The Foundation of Respectful Health Care

Certain things in life translate directly between cultures, transcending the barriers of language and ethnicity and the contentiousness of religious and political differences. One of these things is civility. Civility is not situational. It is not something that applies only at home or at work. It applies every minute of every day to every individual. It is impossible for any self-respecting individual to deny that civility is not relevant to his or her life, and that it should be the compass for behavior, day in and day out.

According to P. M. Forni, the author of Choosing Civility, civility is a code of behavior based on respect, restraint, and responsibility. (Forni P. M.: Choosing civility: The 25 rules of considerate conduct. Lecture given at International Association of Protocol Consultants, Washington, DC, May 5–7, 2006.)

There are six Principles of Civility:*

1. Respect
2. Empathy
3. Flexibility
4. Interest in other cultures
5. Tolerance
6. Technical skills

* Based on Conetsco C.: Mastering protocol, etiquette, & civility. Presentation at International Association of Protocol Consultants, Washington, DC, May 5–7, 2006.

These principles should be core behaviors of all health care workers. Respect is like air: Take it away, and that is all people can think about. If one has ever witnessed the difference in care between a unit where the staff is respected and a unit where they are not, it is easy to understand the need for respect. Empathy, the ability to understand and share the feelings of another, such as fear, anxiety, or pain, is critical for health care providers, if for no other reason than because we are human. Flexibility is mandatory when one deals with living, breathing beings. As eluded to already, life is not linear and logical. If we are not flexible, disappointment will be our constant companion. And disappointment can lead people to create unhappiness in other people’s day. We cannot be a citizen in the United States, Great Britain, Canada, Australia, and many other countries in the twenty-first century without having an interest in other cultures. Respect, married to an interest in other cultures, is a recipe for a successful practice in ethnically diverse countries, as it translates into tolerance.

Many readers will assume technical skills refers to the ability to diagnose and treat a patient. Although that is a part of the civility component, perhaps the more important technical skill is that of effective communication. Communication is a learned skill, and one that we in health care have woefully neglected to the detriment of our patients and employees and safe, high-quality health care. For the better part of a decade, I have promoted physician leadership as the key to health care’s ills—plummeting patient satisfaction, malpractice spiraling out of control, patient safety violations, and health care practitioners who discourage young people from entering a profession that can be rewarding in ways others cannot. I now believe the key is more basic and understandable than leadership. The key is civility: from and between providers, patients, families, administrators, and even attorneys. As I have continued to work in the healthcare consulting and training space, it has become even more clear to me that it’s even more basic than civility. I now believe that kindness is the core requirement of all else in healthcare.

Kindness is the quality most needed in healthcare.

Perhaps the most important thing we do in life is interact with other human beings, such as with our spouse, our children, our parents, our friends, and our coworkers, and in health care, with our patients and their families. Dr. Forni notes, “[A] crucial measure of our success in life is the way we treat one another every day of our lives.” (See reference above) As providers we interact with patients who feel vulnerable and afraid. Health care providers’ relationship skills determine the quality of the health care experience for all involved, whether they are the patient, the nurse, the aide, the physician, or the pharmacist.

At first blush, the need for civility may seem obscure. However, closer examination leads one to conclude that civility is the key to transforming health care. Common knowledge does not automatically result in common practice. As Dr. Forni eloquently states, we all have equilibrium. We all have balance, but that doesn’t mean one who has never been on a bike can simply get on and pedal away. We all have the ability to float in water, but first we must learn to swim. To use a computer analogy, we all are made with the hardware to run the civility “program,” but we might have loaded the wrong software (that is, learned less-than-civil behavior). Physicians, particularly, may run the wrong software, “downloaded” during training, as so much of our behavior is learned. What about kindness? Kindness is an innate trait of humans. Kindness isn’t an emotion, it’s a behavior. In other words, acting unkind is learned behavior. 

The reader, particularly providers, might wonder why the Principles of Civility are important. After all, most providers I know would claim they act with civility on a daily basis. Reality tells us differently, and again, we often don’t know what we don’t know.

Consider the data that tell us civility is a problem, and consider that there are clear social and personal benefits to acting with civility:

1. Civility is connected to the principle of respect for other people. A civil individual treats all others as ends in themselves, as intrinsically valuable individuals, rather than to serve some immediate need or desire. The latter is, in essence, slavery. In health care, a common observation is seeing physicians treat nurses and other providers as “tools of patient care,” instead of as valued team members. Such treatment is disrespectful and counter to the team-based care approach that has been demonstrated to be superior to traditional physician-centric care.
2. There is a connection between incivility, business results, and violence. In the everyday workplace, acts of disrespect are spiraling out of control. More than 45% of respondents in a survey of 800 people conducted by the University of North Carolina at Chapel Hill’s Kenan-Flagler Business School contemplated a job change because of rudeness; 12% actually changed jobs. (Jacoby, N.: Etiquette Crisis at Work. CNN Money, Nov. 29, 1999. http://money.cnn.com/ 1999/11/29/life/q_manners/ (accessed Mar. 29, 2007).) A number of violent incidents has been linked to incivility in the workplace. You might ask what this has to do with health care. Thirty percent of 1,200 individuals interviewed knew of a nurse who quit his or her job because of a physician’s behavior. (Rosenstein A.: Original research: Nurse-physician relationships: Impact on nurse satisfaction and retention Am J Nurs 102:26–34, Jun. 2002. ) The turnover costs to organizations is horrific, estimated in 1997 dollars to be $150,000 per disruptive physician. (Pfifferling J.: Managing the unmanageable: The disruptive physician. Fam Pract Manag 4:76–78, 83, 87–92, Nov.–Dec. 1997.) Furthermore, the data strongly suggest that physician violations of the principles of respect and empathy are the major generators of medical malpractice claims. Multiple small violations of trust by the physician—habitually being late in the clinic, telling patients they will call with the lab results and failing to do so, interrupting, limiting questions or controlling the conversation during the office visit, and failing to apologize for the various violations of civility—create conditions that lead patients to sue when an outcome is less than expected. Patients are angry at the physician before the outcome that leads them to sue. The unexpected outcome is simply the proverbial straw that breaks the camel’s back, leading the angry person to sue.
3. There is a connection between civility and personal well-being. The quality of our personal lives depends on the quality of our relationships with others, but the quality of our relationships depends upon our relational skills. The six Principles of Civility serve as our guide for how to behave toward our fellow humans. Each principle can be learned and cultivated, if we are open to self-examination and honest feedback from those around us. And to reiterate, acting with civility is not situational.

The Principles of Civility are critical to catapulting us over the hurdles we face in health care, leaving them far behind in the mist of the past. Understanding these principles requires one only to be a human being. Understanding and acting with civility doesn’t require an M.D., R.N., or any other degree. Committing to the principles allows health care providers to be more effective in what they strive to do in the first place: care for others.

The Naysayers

There is no shortage of individuals who will be thinking that they don’t have time for this “fluffy communication stuff”; all that matters is outcome. (I would argue that the fluffy stuff enhances the likelihood of a good outcome!) We have all heard these people muttering under their breath, and their self-justifying reasons for not working on communication skills or any other nonclinical skill that could help them improve their interpersonal skills (which is connected to the quality of clinical care). See if you recognize any of these statements:

• “I don’t have time to be nice.”
• “My time is more valuable than theirs.”
• “Save the touchy-feely stuff for ______________ (fill in your
  not-so-favorite subspecialty or person).”
• “I don’t need to get in touch with my feminine side, thank you.”
• “I don’t get paid for being nice.”
• “I’d rather be competent/good than be nice.”
• “When I’m sick, I want competence, not nice.”
• “I’ll take competence over nice any day.”
• “Nice guys finish last.”
• “Why should I apologize? I made the right decision!”
• “Apology is for the weak.”

I would like to help you destroy these emotionally based, avoidance arguments the next time you hear them. And they aren’t hard to destroy. Each of these statements has an underpinning of errant assumptions that makes them untenable positions. The assumptions include the following:

• Being nice takes more time than not being nice.
• Competence and nice are mutually exclusive.

Neither of these assumptions is true, nor to my knowledge can they be supported by anything remotely resembling data. Furthermore, the only nice guys who finish last are those who are also not smart. To rephrase this, “Nice guys who are also smart will always finish first.” (Personal communication between the author and P. M. Forni, cofounder, Civility Initiative at Johns Hopkins University, Willard Hotel, Washington, DC, May 6, 2006.)

“Nice guys who are also smart will always finish first.” PM Forni

Up next in the Communication Series I will begin to address Relationship-based Civil Leadership as a Health Care Business Strategy

All content from In A Blink, by Michael S. Woods. © 2007. All rights reserved.