Navigating Hierarchy in the Clinical Setting: Working and Communicating with Others (December 10, 2013)

Paul Tedrick
AHA – Chicago
December 10, 2013
11:00AM CT

Operator: This is a recording for the Paul Tedrick teleconference with American Hospital Association Chicago, Tuesday, December 10th, 2013, scheduled for 11:00 AM Central Time. Ladies and gentlemen, thank you for your patience in holding; we now have our speakers in conference. Please be aware that each of your lines is in a listen-only mode. At the conclusion of our speakers' presentation, we will open the floor for questions. Instructions will be given at that time on the procedure to follow if you would like to ask a question. It is now my pleasure to turn this conference over to Paul Tedrick. You may begin.

Paul Tedrick: Good morning or afternoon, depending on which time zone you're in today. I would like to welcome everybody for attending the December National Content Call. Today's topic is Navigating Hierarchy in the Clinical Setting, Working and Communicating with Others. As a reminder to everyone today, this is actually a special content call in that it is a webinar, not just a teleconference, so if you do not have the webinar link, go ahead and send me an email. You can reach me at P as in Paul, T as in Tom, E as in Eric, D as in drum, R as in Rick, I as in igloo, C as in cat, K as in kite@aha.org, and go ahead and send me an email and I will shoot the webinar link off to you. Slides can also be found today on our website, and in the webinar discussion area to the left of your screen, you will see links for that, as well as today's evaluation.

Today's presenter is Susan Hohenhaus. She is the Executive Director at the Emergency Nurses Association, and we are very, very glad to have her presenting to you today. So without further ado, I'm going to turn this over to you, Susan.

Susan Hohenhaus: Great. Thanks very much, Paul. Hi, everybody. Hopefully, those of you on the East Coast aren't buried under snow. I keep getting reports from my committee members who are in house today about not being able to get back East, so hopefully, everybody's staying warm and staying safe.

So I really want to thank Paul and the HRET team for the invitation to speak with all of you. I know that each of you represents an important piece of a challenging health care puzzle, and I'm here to talk about my experiences over the past several years, working with teams, both clinical experts and others, who are critical to the safe and effective delivery of care and to talk about the less than comfortable subject of hierarchy and how it impacts our own and our patient safety, as well as the quality of those experiences. This invitation came about because of what I was hearing from some of my colleagues on our calls about CAUTI and I realize that hierarchy and title emphasis can impact our relationships in this work, as well as in the clinical setting. So the first thing that I'll do is disclose to you that I have a very large, 30-plus year nursing chip on my shoulder, and this is always an uncomfortable conversation to have and I have a pretty significant background in human factors, clinical human factors, engineering, and also in the dissemination of the original TeamSTEPPS program, and that's where I started to see where some of these relationships and challenges to our relationships were starting to impact how we deliver care.

So the first thing that you'll see – and, Paul, if you would switch to the next slide – is why is there no title in the title slide? Even though there was a title on my very first page, it was to give you a sense of where I come from. So there's an RN after my name. My doctorate is in law, policy and economics, so I'm a strange kind of hybrid person; I live sort of halfway in the policy world and halfway in the clinical world. But the reason that we're talking about this at all was, on the CAUTI calls, one of the things that we found was happening is similar to what we hear in the clinical setting. So, for example, here at ENA and our colleagues at the American College of Emergency Physicians, have been debating the use of the title Doctor in the clinical setting and it's created a lot of really heated discussions, which are always fascinating to me. And what my non-physician colleagues were saying on our calls was, when we introduce speakers, we introduce the speaker as Dr. so-and-so and Sue, not Dr. Hohenhaus, and so there was this hierarchy that was being set up on our conference calls. So I talked to Paul and some of our colleagues at HRET and this is my lesson to all of you: Don't bring anything to HRET that (indiscernible 4:38) especially Paul because they'll as you how you would like to fix that, and that's how we ended up with this webinar, so my own fault. But it really became important to us to talk about the fact that we really do need to model what matters on our calls so that it can translate into the clinical setting, so if we can flatten the hierarchy on calls like – on our CAUTI calls and our meetings, then we can get there in our clinical setting.

So I don't know about all of you, but I'm fascinated with the root of words and the history of where we come from, so I wanted to provide a little bit of that to you. So when I did a little bit of a search on what hierarchy actually means, where it comes from, the earliest reference that I could find to it was in the 1380 Oxford English Dictionary, and it really refers to priests and the relationship to God, so it was a system of orders of angels and heavenly beings, and now we more commonly think about it as a group of individuals ranked according to authority, capacity or position. Now, at the turn of the 20th century, hospitals were organized into pretty hierarchical structures, with medical hierarchy at its pinnacle, and somehow this has really endured, even with increased complexity, costs and shifts in educational requirements and in technology. We have maintained a culture of subordination to a superior rather than teacher to learner or partner to partner. So there are good things about our current, kind of apprenticeship model. The mentoring and coordination and direct supervision or modeling of behavior still exists in some places, but mostly, it only exists in temporary situations, especially in academic medical centers, and I'm not suggesting, by the way, that this hierarchy exists in medicine or only in academic medical centers.

It's prevalent in nursing and in other professions as well, other disciplines. I have a colleague, John Webster, who's a retired Naval orthopedic surgeon and when he and I met in the beginning, we didn't get along quite so well. We had some pretty strong opinions and so we started talking about the fact that we come from different places and, at one point, John said to me, “Well, what about all those nurses who eat their young?” and I corrected him because nurses don't just eat their young; we eat everybody and we play with our food before we eat it. So I understand that, in a lot of the literature, our physician colleagues, my physician colleagues and some of you on the phone, get kind of a bad rap about being the people who have any kind of disruptive behavior because it's something that, as human beings, many of us own. It doesn't really matter what the title is after your name. Next slide, please, Paul.

So again, historically speaking, 100 years ago, there was a series of studies about the education of health profession, and this came out of a report in 1910; it was called the Flexner Report, and it was really the groundbreaking reform for how we changed our curriculum in university-based schools, and it was the beginning of a scientific approach, a research approach to the delivery of health care, delivery of medicine and it's been credited with being the foundation that equips our health professionals with the knowledge that contributed to the doubling of lifespan throughout the 20th century. If you get a chance to take a look, I mean it's available online. It's the 1910 Flexner Report. It's a fascinating summary of the history of medical education in the U.S. It includes a discussion of the Hopkins Circle, and Abraham Flexner was one of the members of the Hopkins Circle. And the report really focused on the foundation of that scientific discovery. What critics have said about the focus of the Flexner Report and that foundation has been the heavy reliance on the technical side of the delivery of health care that hasn't been balanced well with the primary role of beneficent healer and the human factors element of care delivery, and some of this is already changing. We're seeing more practice-based learning and core competencies developed across many disciplines. Other disciplines are also embracing the model; however, they're still heavily siloed. Next slide, please, Paul.

So here in the 21st century, not everything's going as well as we would like. We have glaring gaps in inequities in health, both within and between countries, and it underscores our collective failure to share the dramatic health advances equitably. So if you look at what I've listed here as the evolving health threats that we face here in the delivery of care now, there are new infectious diseases, environmental and behavioral risks, a rapid demographic and epidemiological transition and health systems worldwide that are struggling to keep up as they become more complex and costly, and those place additional demands on workers. If you think about it, think about 1910 and think about now. A lot of those evolving health threats are not new. They're pretty much the same of what was happening back at the turn of the 20th century as they are – as we begin the 21st century, so we have inadequate communication, hierarchical relationships and intimidation, fragmented mentorship that lead to sub-optimal patient outcomes and contribute to less than adequate staff and patient experiences. So if we stay siloed and top down, it's going to be very difficult for us to work together across disciplines to address any of these threats, and if you think about it, it's nothing new and we're not learning – you know, I always laugh and go back to, if you've never had a chance to read Florence Nightingale's Notes on Nursing, it's more than just notes on nursing; it's notes on health care, and that came out in 1864. So if you look at the fact that, that she described, that poor conditions lead to an inability to actually be a nurse, you can translate that into being any clinician. But it's a fascinating historical perspective that still exists today and I would say the same thing about the 21st century, or about the difference between the Flexner Report and what we see now. Next slide, Paul.

So I want to talk a little bit about your tribe. So you can use a tribe in a negative connotation or in a positive connotation, and I wanted to leave you this quote to think about and the emphasis here is really not – it's not from the article itself; it's partly my emphasis on the poor teamwork piece and the emphasis of a colleague of ours out of Australia – so this is not a U.S. problem only; this is a universal worldwide problem – and that professional education really hasn't kept pace with the challenges that we're facing. The problems are systemic, there's a mismatch of competencies from – between patient population needs. We do have a problem with poor teamwork and – but the last part of this, the efforts to address the deficiencies have mostly floundered, partly because of the so-called tribalism or this siloing of our profession, and sometimes not just acting in isolation but acting even in competition with one another. So if we flip then and we think about the good things about your tribe, tribes are not always bad if they are non-isolative. So I actually like the idea of a tribe, particularly with a team that you work with on a routine basis. I think that most of us can identify a time in your professional career that you can say was your most favorite tribe to work with and that this tribe was not only part of your professional discipline; it was likely an interdisciplinary team that brought both technical skill and a compassionate framework in which to deliver it without title or superiority. I know for me that that time was back in the early '90s when I was part of a, mostly an evening shift group of people in the emergency department at the University of North Carolina and Chapel Hill, and I remember it as a pretty magical time, and certainly there were challenges then and, you know, our memories are not always perfect when we remember (indiscernible 13:06), but I do remember it as a pretty special time because that's exactly what that tribe felt like. We were all supportive of one another, everybody had a different initial after their name and we didn't really have a stratification of who was the attending, who was the charge nurse, who was the bedside nurse, who were the residents, who were the medical students, who were the nursing students. Everyone had a role to play, but everyone had an equally important role to play while we were working together.

The other piece about tribes though that I'd caution you about is you can identify in a good way with your own tribe, your own team, but be careful about the inter-departmental tribes that can also be in isolation and in competition with each other. Most of what I've seen in the actual on-site and in situ simulation training and active coaching that I've done in the clinical settings throughout a hospital system, a lot of times, those are in the OR, the ER, in labor and delivery, but the challenges that exist in a lot of departments is that people get along fairly well together in their own unit. It's when you introduce someone else outside of the unit, whether it's a code team, a trauma response team or just kind of intra-familial siding between units when you're trying to get a patient transferred, and we're really always – we're looking for the same thing so hierarchy isn't always about initials either. It's also about who might feel that their unit is more important than another and how do we make sure that those puzzle pieces all fit together.

So if Paul would turn to the next slide, I want to give you a very specific example that you can look at every single day in your clinical settings, and it's just a simple question of hand-washing and whether hierarchy gets in the way. I still think that Pronovost ICU work, particularly as it relates to hierarchy, is an important body of work for us to look at and reflect on. Done really great work. It was not always well accepted initially and there was a lot of, you know, that's not my job or that's not your job, and a few years ago, there was an article – there was an interview with the New York Times – it was during our Patient Safety Awareness Week – where Peter Pronovost actually did an interview, and that (indiscernible 15:26) is from Johns Hopkins, and he was looking at the quest for patient safety after the misdiagnosis from a catheter – in a death of a child from a catheter-associated infection. And so at one point in the interview, he talks about trying to improve hand-washing practices and that part of the solution was for nursing staff to make sure that physicians washed their hands and if the physicians didn't wash their hands, the nurse would stop the procedure. Well, in the interview, the question was to Peter Pronovost, “Well, how did that fly?” and his response was fascinating. He said, “You would have thought I started World War 3. The nurses said it wasn't their job to monitor doctors. The doctors said no nurse is going to stop take off. And so Peter said, you know, physicians aren't perfect and we can forget important safety measures, and nurses, how could you permit a physician to start if they haven't washed their hands? So as a leader, he stepped up to the plate and said, “If you have this issue at any time, please call me day or night,” and he said in that four-year period of time, when they sort of laid that ground rule, that they got their infection rates down to almost zero in the ICU. So it's a great outcome but the strategy wasn't well accepted initially. Then later in the interview, he talks about the benefits of empowering nurses and others in avoiding that hierarchical structure that we see in so many settings.

We had a similar experience, and when I worked in the Patient Safety Office at Duke University in the health care system and there was a lecture that was being given to a group of medical students, and Karen Frush, who was my boss at the time, asked the question of the medical students, “What would you do if your resident didn't wash his or her hands?” And there was a look of panic on faces and, you know, I would have to challenge my resident to wash their hands? And so Karen said, “okay, I didn't wash my hands,” and she's the attending and they were even more appalled that they would actually have to speak up, and part of that is it's uncomfortable to speak up. We're doing a better job with it but it's particularly difficult to speak up to people who are going to do your evaluation, who are going to impact your career for a long period of time. So you have to ask yourself the question, how comfortable are you with your team and what approach would you take in reminding a colleague to wash his or her hands. It's a pretty fundamental discussion to have when you're talking about stopping healthcare-acquired infections if we can't even challenge one another. I always laugh; my clinical background has been heavily focused on pediatric emergency care and a three-year-old has no difficulty saying, “did you wash your hands?” but we have more difficulty doing it as adults. Next slide.

So you need to look at hierarchies as the Berlin Wall of patient safety and how do we tear down that wall? We really need to maximize patient safety considerations by taking that hierarchy to be balanced in favor of teaching and learning rather than the exercise of power. The unequal balance of power means that novices are typically silent when they should speak up, not because of poor training; because they have few options and they want to progress and a lack of patient safety principles is not always in the agenda for training. We talk about having a patient safety curricula, but we are separating out a patient safety curricula rather than focusing it and inspirating (ph) it in to what we do every single day. So the discipline hierarchy needs to more fully move towards that patient-centered approach and a whole system approach that focuses on team responsibility and not on hierarchy. Next slide.

So I want to give you a couple of examples and how you can take something that can be a pretty challenging situation and create a positive approach to that. So in the first example, I call it ‘Does Anyone have Anything Else to Add?' This was an event that happened in a major medical center. It was during resident rounds at the bedside. It was a pediatric intensive care unit and the agreed upon language – they had been on a teamwork journey for a while, had agreed on standard language and the – what they had agreed on was at the end of the presentation of the patient and they were ready to move on, then the fellow ould say, “Does anyone have anything else to add?” Everyone seemed to be on board during the presentation of the patient but the attending wasn't quite buying into this new approach, partly because I don't think anyone had ever involved him in the discussion. And so when the fellow said, “Does anyone have anything else to add?”, the attending's comment was, “Yeah, how about somebody leaves the room and goes out and asks the housekeeper because maybe the housekeeper has something to add to the complex care of this very difficult patient to manage,” and he kind of shut everybody down and nobody knew quite what to say. You know, this is the attending that was challenging it back.

So the first thing that I wanted to do – you know, I'm in a hospital as a consultant and I'm thinking, okay, how do I get this guy fired because obviously he is not on board with this process, and I stepped back for a little bit and kind of took a break and cooled off, and then I went back and sat and chatted for a little while with the staff, and they said, “Well, we can't really get anything to happen here because whenever that attending's on,” and so it was always blamed that it was that particular attending or it was that particular nurse and rather than taking some ownership about how we approach it. So I started watching the team behave the rest of the day, and what I noticed was that attending was actually modeling some of the behaviors without even knowing it and without anyone acknowledging it. So we sat down as a team at the end of the day and said, okay, obviously we got off to a bad start. We're allowing certain behaviors to progress because they come from a person in authority rather than how do we flatten that out and ask the question, and we mentioned the fact that it had been done really well in some situations and not so much in others and once the open dialogue began, it was amazing how it kind of flipped and we were getting positive feedback. We spent so much time coaching negative behavior rather than finding that, what I call the positive deviant. Find the positive deviant in the behavior or the person who's doing the work well and incentivize that rather than disincentivizing or blaming the rest.

So the second one I'll talk about has to do with blame and it's about a bedside calculation. So a colleague of mine, Suzanne Gordon, talks about a nursing student who told a story that she felt invisible and told she became the focus of a shame-and-blame event. She was observing a procedure when a more experienced clinician was asked to do a calculation of a medicine, and the other clinician kind of froze, and so the attention was turned to her and she thought, well, this isn't going to go well regardless of whether I answer correctly or if I answer incorrectly, and she said, “I'm just going to answer the question.” She answered the calculation correctly and the senior clinician in the room turned and said, “See, even this nursing student could do this.” You know, you could spend an hour debriefing that one incident but it was never discussed and we rarely discuss when we have that kind of an incident occur. So make sure that when you do see an incident, that something like that happens, that you either see it or it's reported to you, particularly those of you in leadership roles, is sit down and have a conversation. It's not easy to have the conversation but when you become more comfortable with giving people the power to do it on their own, that shame-and-blame culture tends to go away.

The third scenario that I'll tell you about that began with a toxic hierarchy but actually is one of my favorite examples of probably most of the work that I've done in this field was working with a group of hospital systems in the Midwest and we had been doing a teamwork training for about 300 people and the discussion about hierarchy came up, and we made the comment, my fellow faculty and I made the comment that what we know from aviation particularly is that when first names began to be used more commonly, they found that the – it was much easier to either challenge respectively or to speak up between the cockpit and the cabin. And so we talked about that being a factor in health care. How do we reduce the use of titles and go to first names when we know that people in other disciplines and other industries used first names? And I had a feeling that, in this large group of mostly academics, that someone was going to raise their hand, and sure they did and it was actually a physician at first who said, “Hey, wait a minute, you know, I spent a lot of time going to school. I want to the right to be called doctor.” And I didn't respond. I waited a little bit and I waited until it happened in the back of the room that someone else raised their hand and said, “But wait a minute, I'm a Pharm.D., and I work in the same health care setting and I'm not called doctor,” and the conversation then wasn't with me and the group; it was between the group trying to resolve how they were going to come up with.

And in the very back of the room, I noticed a surgeon who was in the back of the room and he'd been – he actually didn't do any surgery for a couple of days to be in this training, so he was committed but I could tell he wasn't buying this title thing, and I thought, oh boy, here we go. You know, all of this conversation that we've just had and we've just lost this guy who's going to be a great – could be a great champion but I'm not sure that we're going to get there now. He just kind of sat back, crossed his arms and didn't say anything for the rest of the training, and the next morning, it was – the health care system decided that, because this was an instructor/trainer type course, that the next day that some of the people that were in that course were going to actually do some presentations back to their own staff. So I went – those who were faculty went with a certain group of people so that we could back them up, and we went into one of the units where this surgeon that I talk about had worked and we got a phone call that said that he would like to come and address the group, and we thought, oh, we don't even know where this is going, and it was standing room only. There were nurses, there were residents, there were respiratory therapists, there were pharmacists and it was a pretty small classroom and everybody was packed in, and this surgeon came in and he said, “I want to give the leadership lecture.” Okay, let's see what happens.

So pulled up the slides and he turned to the group and he said, “Good morning. My name is Greg and from this moment on, we start over.” It was truly the most effective leadership message that I've ever seen done in a moment like that, and when I talk about it, I still kind of get goose bumps.

So I'll take my goose bumps and go to the next slide because I want you to think about what plasticity means versus what dominance means, particularly in an institutional and cultural resilience and embeddedness factor. We have not given a lot of adequate weight into shifting the educational and organizational and policy agendas towards inter-professional practice and inter-professional education, so we're starting to see that trend happen in the academic setting. We've got to translate it better, and as my friend John Webster said, that plasticity piece, we need to be more fluid because flexible is too rigid.

So next slide, I want to give you all a chance to do a little bit of voting. This is where they usually ask me to figure out how we can stump people, so I want you – I want to know from you, do you think hierarchy is always bad? And so (overlap).

Paul Tedrick:  And the voting is open. We'll go ahead and give you a good minute to answer. And I'm going to go ahead and push the results.

Susan Hohenhaus: Ah, good. Wow, that's really good. Okay, so let's talk about that for a little bit, and I hope that those of you who voted for no thought about it in this way, is that the good part of hierarchy is particularly important when it comes to conflict, because hierarchy in terms of increasing authority, so you need to kick it up to the next level, is kind of like if you think about a whistle-blower or grievance policy or a safety issue. You have to have someplace to go so you have to have that next level of authority so that if concerns aren't being addressed adequately at the first level that you approach, that you can – it can be helpful to resolve those particular problems. So very nice that most of you recognize that. It's a little difficult to know if you had any other thoughts about that, but maybe we can get to that at the end of the presentation.

So, Paul, you want to do the next question to vote on? So what can be done as bad hierarchy is enforced by the C-Suite, so we talked about what bad hierarchy might be and a little bit about what good hierarchy is, but what's happening if it's (ph) enforced?

Paul Tedrick: And we'll give it another 30 seconds. And I'm going to go ahead and push the results.

Susan Hohenhaus: Great. So it's kind of stacked question, right? You know, you're pretty much led to the fact of a standardized communication approach. I think most of us would be tempted to do one of the first two things, and I'm not saying that revolution is a bad thing and there may be times in your professional career where you're going to feel like you need to draw a line in the sand, and whether that's speaking with your feet and leaving a particular position or banding together with colleagues to address a specific situation, those aren't necessarily bad things. But using that standardized, agreed upon communication approach, you really do have to have leadership buy-in if you're going to be using some of the teamwork skills and communication, the standardized communication approaches that are out there. And, you know, I referred to the TeamSTEPPS curriculum and the TeamSTEPPS tools pretty commonly because, from my perspective, they're the only thing that I've seen in probably most of my career that have some good solid evidence behind them and also an easy way to implement and activate them in – by individuals and by groups.

So let's go to the third question and then tie them together. So what communication tools can be used to break down the bad hierarchy and support the good? That should save you, Ken (indiscernible 31:10). Because of you, we're doing this kind of quick.

Paul Tedrick: Couple of people voting for the first one, ‘change their mind'. And we'll go ahead and push the results.

Susan Hohenhaus: Oh great. Again, stacking the deck here on this one by talking about TeamSTEPPS, but CUS is a tool in TeamSTEPPS, but it's C-U-S. We could add our own little S on to that if we wanted to, but that was just kind of to make you smile a little bit, and I do want to talk a little bit about the third one about sending an angry email because, for any of you who have ever thought about how you approach a bad situation, and quite often people will tell you, you know what? Write it all down, get it out of your system, vent and then throw it away or put it in a desk drawer, and I bet you that there are people on this call that have typed an email that you never intended to send and hit send instead of hit delete. So be careful that if you are venting, that you do it in an appropriate way and then kind of fall back on your standardized communication tools. So I'm really glad that we're going to have an opportunity to talk about what those tools are, so Paul, the next slide.

Because this is just an example, and there may be some of you on the call who haven't been exposed to the TeamSTEPPS curriculum. I put this up there so that you can take a look at the AHRQ website. If you just Google sort of TeamSTEPPS, you're going to come up with that material. So let's go to the next slide and talk about where hierarchy can play an important role in both the negative and in the positive.

So if you're using your – if you're using good skills, you're using an assertive methodology to state your concerns but you're going to do it in a respectful way, so that assertive statement has an opening, says what you mean, state your problem. It also is a solution and it also requires you to reach some kind of an agreement or to escalate it, so that's where the good hierarchy comes in. You need to have an opportunity to escalate an issue to the next level if you can't find a solution or reach an agreement together. Next slide.

So what TeamSTEPPS reminds us to do is, as expert leaders, expert leaders organize a team. Does that mean that other people can't organize a team? Sometimes an expert leader is so overwhelmed in a situation that a non-identified leader might need to step up or someone who is a situational leader needs to step up and pull the team back together. They articulate clear goals. They make decisions through collective input of members, and I emphasize this next one: empowering members to speak up and challenge when appropriate, and I'm taking that directly out of the TeamSTEPPS curriculum but I'd like you to think about that ‘when appropriate'. Timing is important but it's never not appropriate to speak up and challenge, so it may not be during a resuscitation that you want to speak up and challenge unless you think that it's immediate danger to the patient or to the staff. It might be something that, timing-wise, you have to talk about later on, so that's what we mean about ‘when appropriate', when the timing is right. And you can imagine, if you spoke up in a situation – and maybe this has happened to some of you – if you speak up in a situation, that can actually throw fuel on a fire, it doesn't serve anybody well, so sometimes you have to just kind of step back from your own emotion and ego for a minute to try and figure out when do I actually bring this up and what's the threat to the situation right now. And also, good team leaders who are worried about how they come across from an hierarchical perspective, actively promote and facilitate that teamwork and are skillful at conflict resolution. Next slide.

So there are barriers to team performance that have been evidenced in the literature in the past, but this is a slide taken directly from the TeamSTEPPS curriculum and I emphasize two places here. One is that we already know that hierarchy is a barrier to team performance and hierarchy leads to conventional thinking, so if we're going to blow up the model, we need to really focus on those two things. If you look at some of the other things that are barriers to team performance, you can see how each one of them is integrated like any other piece of a puzzle. But, you know, cross walk over hierarchy to lack of role clarity or workload or conflict, lack of coordination and follow-up, we can have pockets excellence in our health care setting that address these things, but we need to look at it from a systems perspective. Next slide.

So high performing teams hold shared mental models. We are all working at the same picture and seeing a similar thing and sometimes having everybody talk about what they see as a potential for a problem or where we are all going can be helpful, whether that's in – sometimes we can do what we call rocket rounds. You know, at the beginning of a traditional shift or during a huddle midway through the day, is to say, okay, this is what I'm thinking, this is what I'm thinking, this is what I'm thinking. Got three different perspectives that have come forward and make sure that everybody's all in that shared mental model space. Clear roles and responsibilities, I think – when I first started doing this work, I thought that the focus on the team roles and responsibilities wasn't as critical as perhaps mutual respect or leadership development, but I'm finding more and more that it's really important that everybody understands their role and the responsibilities that they have to team and that actually helps to flatten hierarchy and improve patient safety.

And I emphasize this one line here as well, is that by doing so, we develop a really strong sense of a collective trust and confidence in one another, and if you've never explored the teamwork literature that's out there – and this is not just in health care – but if you get an opportunity, take a look at the work of Ed Sallis from University of Central Florida. He's probably one of the best gurus out there for teamwork behavior in aviation, nuclear power and also in health care.

So I'll make a couple of final points and then have Paul open up for questions if you need them, and on the next slide, what I want to talk about is, it's funny how sometimes you go back to a publication that you wrote a while back and you forget that there were elements of that that you want to be reminded of now and then, and this was one of them for me. Karen Frush and I published an article back in 2005 about revolutionizing the health care system. Probably nothing in it that most of you don't already know but I needed to be reminded of a little bit, and that this – we wrote this about status and ego remaining at the door of a meeting room and that all safety team members should have equal authority to identify issues and challenge unsafe practices, regardless of title. Next slide.

So if you think about this quote, “The most important scientific revolutions all include as their only common feature the dethronement of human arrogance from one pedestal after another of previous convictions about our centrality in the cosmos,” it's really about the revolution that should occur in all disciplines, the obligation to both model team behaviors and respectfully challenge traditional hierarchical culture belonging to each one of us. So I'll leave you with the last slide and this thought, is that what we model matters. If we could change ourselves, dependencies in the world would also change. As a man changes his own nature, so does the attitude of the world change towards him. “We need not wait to see do what others do,” and that was a Gandhi quote.

So I thank Paul and his team, once again, for this opportunity and happy to entertain any questions.

Paul Tedrick: Operator, you can go ahead and start the question-and-answer process and make sure to give everybody instructions, please.

Operator: Thank you very much. Ladies and gentlemen, at this time, we'd like to open the floor for questions. If you would like to ask a question, please press “star one” on your Touchtone phone now. Once again, if you would like to ask a question, as a quick reminder, you may press “star one” on your Touchtone phone now.

Once again, to ask a question, you may press “star one” on your Touchtone phone to ask a question. Our first question will come from Barbara Edson, HRET.

Barbara Edson: It's not a question, so much to thank you very much and we really appreciate your time discussing this important topic. You know, having worked in TeamSTEPPS and around culture, not just with the CUSP CAUTI program but with TeamSTEPPS in general, l can't stress enough the importance of that ability to go ahead and function in a team where folks are respected and listened to. It comes clearly in all of our literature and certainly the teams that have been very successful in moving towards improvement in not just CAUTI but really in any care setting, so I do appreciate it. I just wanted to say thank you very much for your talk today.

Susan Hohenhaus: Thanks. I'm kind of in awe, what people are saying up in the discussion area right now. Thanks, Barb.

Operator: Thank you. Once again, if you have a question, just (indiscernible 41:24) press “star one” on your Touchtone phone now. Our next question will come from Tina Adams, HRET.

Tina Adams: Hi, Sue. This is Tina and I just wanted to thank you for this presentation. I think it's an extremely important discussion for all of us to have. I did want to ask you a question in relation to the immediate next steps that a nurse or (indiscernible 41:56) health care worker can utilize when they're in an incident in which a person higher on the hierarchy has insulted you or said something that was inappropriate in mixed company or whatever it might have been that was professionally demeaning in some way. How should the nurse respond to that in real time, and how should they proceed to work with that individual in the future? Thanks.

Susan Hohenhaus: Great question. A couple of things. One is you're going to have to lay a foundation for yourself about what some of the tools are that are out there, and it takes practice to do it, so whether you go back and you look at the AHRQ website for some of the TeamSTEPPS communication tools that there are, you also have to practice kind of your game face. So if it's happening in real time, if you've practiced ahead of time, you know, kind of give yourself a scenario, look in the mirror and say, “I'm sorry, can we talk about that later?” and it kind of brings a heads up to the conversation. If it's something that's actually impacting the patient safety, then you can use whatever stop the line phrase that you would like to use, but if it's a behavioral issue that you want to be able to address but it's not impacting safety right then, then I would just probably practice some kind of a line like that, like “I'm sorry, can we take – can we talk about this later?” and then really follow up and talk about it later. And it's okay for you to have a one-on-one conversation. I would probably have a witness, whether that's your manager or someone else that you respect in authority to say, “I feel, when you said that to me” – and always put it back in your own conversation – “when you treated me that way,” or “when you said that to me, it made me uncomfortable and the reason that that made me uncomfortable was because, in the future, I'm going to be less than willing to speak up and that actually might impact patient safety.” So you've actually used a tool without even knowing it. You said, “I'm concerned, I'm uncomfortable, this could be a safety issue,” and that's a CUS tool that's in TeamSTEPPS, and how you continue to work with that person professionally is the more that you respectfully challenge, then the behavior – the line of the behavior needs to be, “you can't talk to me that way.” Only, if you say it in a negative or confrontational way, you're probably not going to get very far. If it continues to happen, then you've got to figure out a way to escalate that to the right place, and sometimes it's two or three levels of the hierarchy that'll help you get there.

Tina Adams: I appreciate that, Sue, and I did want to say that I appreciate the concept that the communication from the nurse or other person who (indiscernible 44:57) to bring it back around to patient safety and speak up future (ph) and that that might be a detriment to the patient but it would also perhaps be a problem for the physician if he was unaware – he or she were unaware of the patient concern that you might have brought to him but now you're locked in (indiscernible 45:19) because of his behavior or her behavior.

Susan Hohenhaus: Right. Those are great points.

Tina Adams: Thank you.

Operator: Thank you. Our next question will come from Kelly Faulkner, HRET.

Kelly Faulkner: Hi, Sue. This is Kelly. Thank you so much. I wanted to just take this opportunity given your specific expertise in the emergency department. I'm wondering if there's anything you'd say to someone in an emergency department that might be an addition or related to maybe the handoff and transition. So as you likely know, we recently opened the emergency department component of the CUSP CAUTI project, and right now, we have about 125 units so many of them may be on our call and starting to work in paired teams with the inpatient units, so is there anything from that perspective that you might add to this or want to share?

Susan Hohenhaus: Sure. Sure. So – and maybe I'll share a little bit of history of my first involvement with the CAUTI project in my current role at ENA. Was sort of a – I got invited to be on a call and that kind of led to our work with CAUTI, with HRET, and it was about placing urinary catheters in the emergency department, and one of the questions that came up on the call, or I guess one of the points of data was that when they reviewed – in an academic medical center, they reviewed the number of Foley catheters that had been put in – that had been put into patients in the emergency department, they felt it was appalling because 60 percent of those urinary catheters did not have a physician's order, or a provider's order to put them in. And another colleague of mine, who is an emergency physician, was also on the call and we were texting each other back and forth and we were, like, “only 60 percent?” because there wasn't an understanding about how an emergency department works together and – or maybe how another unit works together, is – we didn't really examine that, is that the challenge there is what's the hierarchy? Does it work in an emergency department, that an emergency nurse follows a certain set of guidelines and just goes ahead and places a urinary catheter, or doesn't place a urinary catheter, because the question that ended up coming up was, who has authority to do this? What does an order mean? What is a guideline, and how do we work these things together ahead of time so that we aren't placing unnecessary Foley catheters?

And then the conversation became, well how do we get nurses to stop putting in Foley catheters? And I was really puzzled by that because the protocol was always, if it was this kind of a patient, you put in a Foley, you put in a Foley, you put in a Foley.

And the other part of the hierarchy of that was if you just say, you know what? The research or the literature shows that we shouldn't be putting in as many Foley catheters, we got to change our protocol so that isolation in the emergency department, we all say, “okay, fine, we're not going to put in so many catheters; this is what we're going to do. We're going to advocate for our patients,” but then the first time that you actually try and transfer the patient to another unit – and this is not just true of the emergency department; it happens from floor to ICU, from OR to floor, from ICU to floor. These things happen all the time, when that interdepartmental hierarchy sometimes happens, where you walk in and you say, “okay, we didn't put the Foley catheter in because this is the best practice, this is the evidence that's out there,” and the first question that you get asked by another clinician – and, you know, insert whatever initial after your name you want – is, “why didn't you put in the Foley catheter?” because of the ease of patient care sometimes.

So we had a conversation about that in the beginning, and we've started to look at that, that we can't just talk about the technical skill of put in a Foley catheter or don't put in a Foley catheter or how we do it. We have to talk about how we respectfully approach the conversation about whether we should be doing it in the first place. Does that answer your question, Kelly?

Kelly Faulkner: Yes, wonderful. Thank you, Sue. I appreciate it. And if there's any questions from anyone about that, about their new involvement in the ED, great opportunity having you on the phone as well, so thank you.

Operator: Thank you. Our next question will come from Tracey Broussard, UF Health, Jacksonville.

Alice Weiss: Hi. This is – yeah, hands-free.

Operator: Tracey, you're live.

Alice Weiss: Hi. Can you hear me?

Susan Hohenhaus: Yes. Are you there, Tracey?

Alice Weiss: Yeah. Let's see.

Operator: We can hear you. Go ahead and talk.

Alice Weiss: Oh, you can. Okay, good. This isn't Tracey but I'm here – this is Alice Weiss. I'm here with Tracey and soon to be (ph) at UF Health Jacksonville. We're interested in maybe stories that people have of early breakthroughs in changing the culture, that is to go from a culture of ego and hierarchical structure to the wider interdisciplinary collaborative team framework, you know, and put that into action. Does that make sense?

Susan Hohenhaus: Yeah, and hey, Paul, can we have about four more hours? You know, I mean there's so many stories that are out there and that's part of the problem, is that we're not being good about sharing our stories, and part of it is we have culture in the health care system and not just in the U.S. but it's a pretty universal thing, is that we don't talk about our mistakes. We don't talk about our challenges because those things impact business. They impact the economics of how we deliver health care, if we report that we've had a bad outcome or we report that we caught a mistake just in time. We don't talk about those things, so we're certainly going to have a lot more difficulty talking about ego and hierarchy in this way. So I think if you keep the conversation focused, kind of like we talked when Tina asked her question, keep the conversation focused on the patient and sometimes it just takes one person to start that revolution of saying, “okay, we're going to talk about this; we're not going to tolerate this behavior,” and you know, go back to the question earlier about you're not going to really stage a sit-in but can you get a group of like-minded people together to say, “we are consistently seeing a pattern of behavior.” Whether it's with a certain person or a certain discipline or department, pretty much what we see, it's not the entire spectrum of one discipline or one system or one department. It's usually, you know, 5 percent or so of the population that are causing the most strife or difficulty, and at some point, leadership is going to have to take ownership of the fact of – whether it's a nurse or a physician or a pharmacist that's able to bring notoriety or – in a good way – or money into a facility that outcomes are going to be poor if you don't address certain behaviors.

And you really can't have other people fix that for you. You're going to have to figure out how to do that, and I think that's why I keep bringing you back to the TeamSTEPPS tools, is that if you actually take that information, there's a great implementation guide that goes with it and there are lots of stories, so if you want more stories, look at the stories in the TeamSTEPPS curriculum because they are case-based and there is one for almost every unit you could think of, all the way to – from dental units to primary care offices to the acute care setting. So if you're looking for more stories and how you can approach them, they are great ways to begin scripting how you respond to these situations.

Alice Weiss: Great, thanks.

Susan Hohenhaus: Sure.

Operator: Thank you. Our next question will come from Barbara Edson, HRET.

Barbara Edson: It's not a question. I just want to go ahead and say yes, Sue is absolutely correct about the information on TeamSTEPPS, and if you're not familiar with the program, I'm sure you're familiar with pieces of it because most people have – most organizations have implemented (indiscernible 53:43) and some of those standard communications. But if you're not familiar with it, there is a website – and I don't know whether, Paul, you can go ahead and type this in – but the TeamSTEPPS portal is one way to go ahead and get involved. If you haven't had training to go ahead and do that, we can go ahead and post that TeamSTEPPS portal, but there's also TeamSTEPPS materials on the AHRQ website as well.

Paul Tedrick: And I'm going to go ahead and post that in there too, Barb. I'm looking it up right now.

Barbara Edson: Thank you.

Susan Hohenhaus: Thanks, Barb.

Operator: Thank you. Well, at this time, it looks like we have no further questions in the queue.

Susan Hohenhaus: Great, so once again, thank you, Paul, and the HRET team for the opportunity to talk, and I wish you all be safe, be well and work together.

Paul Tedrick: And I notice that my colleague just put the portal in there for TeamSTEPPS, so for those of you looking for that link, please link to the discussion area on the left side of your screen. You'll also notice a link to our evaluation, so before we sign off today, I wanted to, first off, thank you, Susan, for an amazing presentation. It was absolutely very well done. And I also wanted to thank everybody out there in the audience today for joining us as well and wanted to remind everybody how important it is that you take a quick moment to fill in an evaluation of today's presentation. I can't stress enough how important your feedback is to us. We use it in a multitude of ways, from improving concerns that you have to working on future content and topic ideas. So take a moment to look at the left side of your screen. You'll see the link for our evaluation and go ahead and fill that out.

And that is pretty much all I had today. I wanted to thank everyone once again for joining us and for participating in today's webinar, and I wish you a very happy and productive day. We'll see you for our next content call in 2014.

Operator: Thank you very much. Ladies and gentlemen, this conference is now concluded. You may disconnect your phone lines and have a great rest of the week. Thank you.