SCCM Resource Library-How Experience Motivates Us

Video Transcription

When you take a step back, patient safety is really about improvement from a principled and human lens.  We will review our common guiding principles, provide a tool to understand the human experience in social systems, touch on team concepts,  and try to apply this to diversity and inclusion. We all come from different backgrounds, we have different life experiences,  we're trained in different fields and different locations, but each of us has taken some sort of pledge or oath. And when you look at them more closely,  we do share some common guiding principles, to see and treat all as human beings, to prioritize patient care over other rewards, such as fame or being a social media influencer.  There's nothing wrong with these, it's just we shouldn't give up our guiding principles to achieve them, to advance our knowledge and improve our practice,  and ensure that this knowledge is used for health, healing, dignity, and humanity, as well as to teach skills to the next generation who commit to these principles.  This slide is meant to celebrate and appreciation for the wonders and complexities of a human being, the whole human being, and that we're not a label.  We have knowledge that's both tacit and explicit, we have wisdom and experiences, individuality, and so much more. But for the sake of PowerPoint, sometimes we might just be boxes.  Critical care medicine was founded on patient safety. People like yourselves on the front lines using the human lens, Florence Nightingale, Ignatius Simmelweiss, Walter Dandy,  the founders of SCCM and so many others, understood that the sickest patients had different needs. They redesigned the system around them.  Peter Pronovost, as a fellow, saw opportunities in which small changes in how we interact with each other in key moments could have a huge impact.  He came up with the daily checklist tool and central venous catheter insertion checklist. Think of what has happened to central line infections.  And Ignatius Simmelweiss, who recognized that hand washing could save the lives of young mothers from sepsis. He worked tirelessly for this cause, but ended up being rejected  and seen as an outcast by academia. And look at his contributions today. I see the spirit of patient safety in so many of you who strive to find a way to do the right thing  as part of your daily routine. We hear the word systems a lot. It should not be meant to confuse us. Systems are made of people, policies, tools, and how they interact.  An ICU is a system symbolized by this oval, but we fit within a larger system of the hospital with administrators, committees, and their dashboards or lens of how they see things.  Payers, governmental, non-governmental agencies, media, all use their own lenses and perspectives. There are very good people in each of these roles  who are striving to do the right thing. Just how we make our decisions in the ICU, each of them have their own ways of making their decisions.  We may not appreciate the complexities of their decisions, just like they may not appreciate ours. Many of their decisions are designed to influence our practice in a good way.  They often help us, but they often are required to move away from the human lens in their roles and may not always appreciate our common guiding principles. I put us at the top.  We are able to use the frontline human lens to integrate the help and support from the rest of the system. And there are many thousands of ICUs.  And I'm grateful for an organization such as SCCM to help us have a voice.  Next, I will introduce an anthropology tool and provide some key examples to help us better understand the human experience in social systems.  This is a basic qualitative walkthrough of a human scenario. If there's one thing that you remember, I hope that is what is in this blue box. What do you see or hear?  What do you think? How do you feel? And what do you do? Think of it as a 2X microscopic lens for human behavior. And it's at the core root of so many important things.  It's an ideal approach for root cause analysis or case reviews, human-centered design, self-reflection of our own biases and actions. It's important with cultural change,  as well as alarm, fatigue, burnout. It's also an important part of behavioral change and behavioral psychology theories. For those interested, behavioral psychologists  show us how each domain can be influenced without us knowing it. Marielli, who studied irrational thinking, shows us how we often think irrationally  and summarizes common influential tactics in his book, Predictably Irrational.  J.B. Watson, in the 1920s, did an experiment called Little Baby Albert. Baby Albert would laugh and smile while playing with animals.  Watson temporarily played a harsh sound during playtime. This conditioned the baby to cry around these same animals.  B.F. Skinner influenced behavior with rewards and punishment and celebrated this as an approach to control humans in his book, Beyond Freedom and Dignity.  Albert Bandura showed us how we are easily influenced by modeling others' actions without thinking.  And there are combined models, such as the Provider Behavioral Model, the Elephant and the Rider Model, the Fog Model by B.J. Fogg,  in which Silicon Valley routinely uses for their app design, and Alex Sandy Pentland's, whose book, Social Physics, celebrates personalizing the information that we see  and integrating these other tactics into digital social networks to change our behavior for good.  Now, back to the human and real-world lens, we can build on this approach to better understand conflict related to human interactions. In managing the same patient,  team members might have differences in any one of these components. And many seemingly big conflicts can root in some small differences that can be identified and overcome.  We can use this same approach to understand our interactions with alarms, pulse oximeters, and other parts of the system.  Here's a basic example when a physician is placing a central venous catheter and the nurse sees a contamination. The nurse sees a contamination.  The physician hears, stop, and thinks, what, why? I'm really behind.  The nurse knows that it's for patient care to prevent an infection. They both have some momentary grumblings, but at the end, they do the right thing  and stop and restart the procedure.  And here's a common alarm example. A nurse who is helping out one patient hears the other patient alarming. What do you think? Which one's my priority? Am I doing the right thing?  What do you feel? Some stress, initially helpless about helping both patients simultaneously. What do you do? In the moment, you must choose one over the other  and you just do the best you can. But what do you do in the long-term?  And good people are working on this, but we must create solutions to empower the nurse to care for both patients. We must identify and overcome.  Because if you don't and you repeatedly keep this nurse who's trying to follow guiding principles and do the right thing in this helpless state,  eventually they can develop alarm fatigue, which is learned helplessness that leads to not caring anymore.  And alarm fatigue is just burnout that's specific to alarms.  We will highlight factors for team performance, including shared mental models, trust and orientation, and touch on development and performance with a key example.  Here we highlight the key factors for team performance, such as shared mental models. You know, what's a common vision for ideal care for this patient? What's our common goal?  Do we agree with the same goal? Words, their meanings, and roles and responsibilities with support and overlap, because we all work to help each other out.  There's mutual trust, accountability, and supporting each other to do the right thing, and knowledge, skills, and attitudes. We try to help and lift each other up.  And a lot of this work has been developed by the TeamSTEPPS program at the website listed.  In critical care, we commonly create new teams around specific patients. We have new trainees or staff turnover. And the first phase is this forming  in which people are coming together. Next is this storming in which we're noticing gaps in our mental models and other factors.  We can develop team friction or recognize some differing agendas. But then we work through these into norming and performing.  The graph on the right maps this out over team performance. The first is forming as a group. Our performance is usually equal to the sum of our individual parts.  But then we can get to this storming phase and develop a pseudo team in which our performance drops. This is when we're out of sync, we have differing mental models,  we may not have the same structure, team friction, we may not have the similar orientation for our patient care or any of those other factors.  But we work through this into developing a potential team and eventually develop synergy to create a real team or a high-performing team. And this is not a number, but a feeling.  Because you know it when you work through all these with a group.  And the reality is many of us work up in this zone and don't appreciate it. And programs like TeamSTEPPS or other simulation programs  can really help us work through this much more quickly. Here's an example of a preventable cardiac arrest. In the background, there was a push nationally against bullying.  Bullying is bad. Hospital administrators wanted to help. They implemented a stop bullying campaign to make everyone aware. There were flyers posted around the ICU and the wards.  The doctor who was taking over the ICU service received sign out the night before. This patient was a post-op day number two status post open repair of a ruptured AAA.  She was vented in congestive heart failure and renal failure and also on a LASIK strip.  At 7.30 a.m., the new nurse who had been caring for the patient over the previous days and talking with the consulting and primary physicians  was in the room with the patient's daughter telling her about the care plan for the day based on the previous day's diagnosis.  The doctor reviews the chart and takes one look at the patient and recognizes that they're in septic shock and multisystem organ failure and about to code in a few minutes  if we don't change directions. There was a directive order to do so. And the nurse responds with repeated questioning without initiating treatment.  Then these two pathways are occurring simultaneously. The doctor has to reach out to other nurses. The family member calls the patient advocate  who requests to remove the doctor from the patient's care. And the patient eventually develops PEA arrest. And we can look at this in a little closer detail.  This is a basic walkthrough where the physician sees a sick patient who needs immediate change. The nurse hears a directive order that's contrary to sign out,  thinks there's some sort of bullying here, has a negative emotion towards the doctor and resists, while the doctor feels helpless in knowing a code will happen  and finds others to help out. And for those interested, this is an example of the elephant and rider model by Jonathan Haidt in which a good person  with good intentions can have their stress response amplified misdirected towards their own team member.  This is clearly a pseudo team that almost resulted in a death. And administrators who felt like, you know, this bullying campaign would promote people getting along  and working well as a team were all ready to reprimand this doctor and had this patient not coded, the doctor would have been labeled as not a team player.  And similar to alarm fatigue, when a person is helpless against appeasing their guiding principles, such as right care right now and not being perceived as a bully,  over time they might eventually give up and stop caring about their guiding principles.  So can we use these concepts for diversity and inclusion?  My colleague told the story of Elijah McLean's mother's experience in the hospital in a talk entitled, It Starts With Us.  Before any judge or jury, her son was labeled as a criminal. This was passed along between handoffs and staffs reportedly were repeatedly pushing her  to withdraw care without engaging her like they normally would. And she just wanted to be seen and treated as a human and the mother of her child.  So in that moment, when we hear descriptions or somebody labeled as a criminal or an alcoholic or from X country who speaks X language, what do you think, feel and do?  Do you see them as an individual, acknowledge and appreciate their differences? Do those differences drive you to explore more to optimize their health and dignity?  What does it make you wanna give up sooner?  Patient safety provides us with guidance for active listening. This is a fishbone model to help us map it out. We put a very specific problem  or human-centered ideal solution on the right. Then we listen closely to identify the things such as barriers, facilitators and other targets to identify and overcome.  Did Ms. McLean provide us with a human-centered solution? And what that would mean would be to see and think and have our emotional responses and actions  all appreciate each other as equal human beings and with their humanity.  In critical care, we have to sometimes focus on organ systems to best get our patients back to their previous baseline. But we also need to remind ourselves  that we did not cause the disease, but our role is just to do our best. These are some stories from different sources and lectures including Uncloaking the Invisible  by Dr. Gu and Dr. Gupta. Dr. Gu gave us a history of how government officials and the media in the 1880s created propaganda in order to initiate violence against Chinese and others.  She describes how the entertainment industry dehumanizes and hyper-sexualizes for money and entertainment. Academics promoted eugenics  and all three coordinated to implement and justify Jim Crow and other racist laws, mass lynchings and all of the other horrors that my words can't do justice.  But even in 2021, after a murder of a man in San Francisco, she described how the district attorney called the crime a temper tantrum.  The pulse oximeter is a good example of how we interact with devices and other parts of our system. Jack Awashina is presenting on some work  about systematic error in pulse oximetry. For patients with darker skin color, there's a wider range of error at lower saturation levels. So displayed saturation of 89%  might actually be closer to 85%. Think about how that impacts decisions such as who is sent home from the emergency room, who's hospitalized, who is sent to the ICU.  And what does that mean for their outcomes? And Dr. Thomas from MIT, who looked into this decision a little further. And in the 1970s, despite Hewlett Packard's engineers  developing a good cross skin tone oximeter, the FDA did not require this for device companies. They knowingly used the lack of statistical power  to embed such a sensor into everyday practice. This systematically leads well-meaning people to unknowingly act against their principles, contributing to systemic racism.  And I thought things like the Tuskegee experiments had ended.  With active listening, we can build and collect each other's perspectives to map this out. This is just a start. With media in Hollywood, we may not be able to control them,  but we can learn to protect our minds from it. With biases, we can dig deep within ourselves to recognize them and their sources. We can find trusted colleagues to help us do this.  It is clearly not something to work out on social media. With triggers, we need to understand and respect each other's, but also to find a way to keep them from dividing good people  who are trying to do the right thing. We can try to start each day with the right attitude and encourage others to do the same. We can assess each policy level decision  with patient safety lens to identify and overcome. We can do our best in the short-term fix, such as understanding a variation  with pulse oximetry, but in the long-term, we must get to a better solution. We can ask people in other roles to see us as humans who are trying to do the right thing  and engage them to appreciate our common guiding principles. This is the way to rebuild with a patient safety approach. And there's patient safety and behavioral science  that can help us with all of these.  Try it. See, think, feel, and act as if each of these people are human beings, whole human beings to be appreciated. We're not a label or a list of descriptors.  For those of you who have worked with artificial intelligence, you might recognize them as classes or how computers see us. Computers do not use a human lens.  And for those who are concerned that we are being gaslit, I do agree.  So remember and remind each other and others of our common guiding principles. Use see, hear, think, feel, and do to help better connect with each other  and understand how other parts of the system influence us. And did Ms. McLean give us the start for a checklist tool that we can embed in our social history?  And use active listening to identify areas to focus on to overcome. We must overcome. Otherwise, we get stuck in a cycle of helplessness where we stop caring.  And that is not the human spirit.  And if that isn't enough to motivate you, otherwise, we will be blamed by other parts of the system, leaving the next generation to pay for the lack of our response.  We can achieve high-performing, diverse, and inclusive teams to optimize health, dignity, and humanity.  Thank you very much.

Video Summary

The transcript discusses the importance of patient safety and improvement from a principled and human perspective. It emphasizes the need to prioritize patient care over other rewards, such as fame or social media influence, and to maintain guiding principles in order to advance knowledge and improve practice. The transcript also explores the concept of systems within healthcare, highlighting the interactions between different individuals, policies, and tools. It suggests that frontline healthcare workers can use a human lens to integrate support from the rest of the system. The transcript introduces an anthropology tool called "See, Hear, Think, Feel, Do" as a way to better understand the human experience in social systems. It also touches on topics of diversity and inclusion, active listening, and the impact of biases and triggers on patient care. Ultimately, the transcript argues for the importance of using a patient safety approach to rebuild and improve healthcare systems.

Asset Subtitle

Quality and Patient Safety, Professional Development and Education, 2022

Asset Caption

The importance of generating a culture of patient safety is well known at individual, team, hospital, and healthcare system levels to reduce errors and improve interprofessional team dynamics, thereby improving patient outcomes. We can translate this attention to safety into creating environments for cultural competence, cultural safety, and environments supportive of diversity.

Meta Tag

Content Type Presentation

Knowledge Area Quality and Patient Safety

Knowledge Area Professional Development and Education

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Quality and Patient Safety

Tag Workforce

Tag Diversity Equity and Inclusion DEI

Year 2022

Keywords

patient safety

improvement

principled perspective

human perspective

healthcare systems

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