TRUST CYCLE: SAVING LIVES, CHANGING LIVES FROM THE BEDSIDE TO THE BOARDROOM
Brian Wong, MD, MPH, Founder and CEO, The Bedside Trust, Seattle, WA
Educational Objectives
| The goal of this program is to improve workplace communication, satisfaction, and patient care. After hearing and assimilating this program, the clinician will be better able to: |
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Discuss the importance of trust in health care settings. |
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Identify barriers to cooperation and teamwork. |
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Recognize one’s personal role in suboptimal workplace dynamics. |
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List the qualities of a TRUSTED colleague. |
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Apply TRUSTED concept to facilitate positive change and effective solutions in the workplace. |
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Wong reported that he is cofounder of The Bedside Project, LLC, which holds a US Patent-Pending application for the TRUST cycle. The planning committee reported nothing to disclose
| Premise: trust is everything; building, supporting, and leveraging high-trust systems helps clinicians save lives; high-trust systems become high-performance systems; lessons applicable from bedside to boardroom, but begin with personal transformation; effective relationships, based in trust, benefit everyone (eg, clinicians, patients, executives, staff) |
| Challenges facing health care systems: “every man for himself” mentality (ie, frustration, isolation, noncooperation) leads to burnout and poor retention, and threatens entire health care system |
| Root-cause analysis: investigation of problem, in search of its source; working backwards from problem of interest, series of “why” questions identifies origin of cascade of events (ie, root cause); identifying and correcting root cause solves problem effectively and efficiently (ie, provides cure, not just palliation of symptoms) |
| “Tribal” warfare in health care: industry consists of many factions or “tribes” (eg, providers, payors, patients, pharmaceutical companies); tribes further divided into many subtribes of increasing specialty (eg, physicians, surgeons, orthopedists, hand surgeons, individual practices); absence of common ground results in tribal warfare and demonizing of opposition; opportunity for teamwork lost; results in overreliance on heroic indi-vidual efforts |
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Isolationism: “if you want something done right, do it yourself”; antithesis of teamwork; concept now the rule rather than exception |
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Root cause: profound lack of trust |
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Solution: restore trust; stop blaming; unite tribes; find common ground; address issues; restoring trust eliminates “every-man-for-himself” mentality, which ultimately leads to suboptimal performance in everything from core measures and patient safety, to financial performance and bond ratings |
| Water cycle in nature: evaporation, condensation, precipitation, runoff; no single element more important than others; sequence of events and appropriate balance required for sustainable system; supports all life on earth |
| Trust cycle: analagous to water cycle; elements—creating environment of trust; finding common ground; communicating effectively and positively; making unifying diagnosis before beginning treatment (ie, participating in root-cause analysis to identify and address problems); application—steps (completed in sequence) facilitate development and implementation of effective, efficient, and enduring solutions to wide range of problems |
| “Tipping point”: concept made popular by book, authored by Malcolm Gladwell; moment at which idea, trend, or social behavior crosses threshold of acceptance (ie, “tips”) and spreads; positive momentum dramatically increases, causing it to “spread like wildfire” |
| Example case: graffiti and crime in New York City—graffiti at epidemic proportions (especially in subway stations and on subway trains) during 1980s; in 1984, new subway director began tackling problem amidst criticism (other issues, eg, crime, considered more important); he considered graffiti as demoralizing evidence of broken system (“if you can’t solve graffiti, how can you solve bigger problems?”), and suggested that addressing problem of graffiti would send message of hope and positive change; at same time, chief of Transit Authority Police Department began targeting problem of “fare jumping” (ie, jumping turnstile to avoid paying fare), which resulted in estimated annual loss of $150 million of revenue; policies (including arresting fare-jumpers and performing on-site background checks) established effective deterrent and decreased crime rates; crime rates in New York City continued to decrease to all-time low (in 2007), while subway ridership increased to record high |
| Identifying the “graffiti” in health care: “petty crimes against people”; pervasive behaviors or attitudes that cumulatively have large negative impact, but tolerated because considered unsolvable; common in many different settings; elimination would improve ability to live “core values” |
| Leadership styles: third-person and second-person approaches identify problem in relationship to others and depend on others to change; first-person leadership identifies one’s own participation in problem and potential contribution to solution |
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Personal anecdote: as medical director, speaker given task to renegotiate contracts for 50 physicians; task required terminating existing contracts, negotiating terms of new contracts, and completing performance evaluations; task completed within 90-day deadline, after which colleagues submitted anonymous feedback; colleagues described speaker as rigid, inflexible, poor listener, disrespectful, arrogant, intimidating, threatening, judgmental, and unforgiving; speaker devastated, angry, and bitter, with sense of betrayal; many years later, speaker realized that while pursuing task, he had embodied traits that he despised and became part of problem, not part of solution |
| TRUSTED colleague: team player; responsive and respectful; understands (listens and learns without judgment); safe; talented; executes task; dedicated and devoted; TRUSTED attributes apply to clinicians, staff, executives, and administrators; absence of any attribute erodes trust; comment on safety—safe refers to patient safety and personal safety (including emotional safety and safe communication) |
| Creating barriers: some behaviors and attitudes (eg, speaker’s list of “personal graffiti”) may seem helpful for completion of task, but actually create barriers; task parameters may be met, but unlikely that results meaningful or enduring |
| Attributes of ideal systems: different groups arrive at similar lists; eg, positive energy, fewer e-mails, teamwork, laughter and joy in workplace; organization, healthy relationships, universal performance goals |
| Attributes of disastrous systems: also similar among different groups; eg, “silos,” too many meetings, dispassionate leaders, loss of history and heritage, loss of hope, unclear vision and strategy, apathy, lack of respect, not serving mission, losing good colleagues |
| Stimulus-response: concept explored by Viktor Frankl (survivor of 4 concentration camps during World War II); unlike simple reflex, most situations allow space between stimulus and response (ie, potential to choose one’s reaction); individuals may choose to become TRUSTED colleagues by choosing how to respond (with, eg, cooperation, respect, safety) in each situation; individual choices create environment (ideal or disaster) |
| Communication: “having conversations we need to have the way we need to have them”; many books written on topic of communication in workplace; speaker suggests that simply pausing and choosing one’s response can improve not only communication but also patient care |
| Action: focusing on small part of problem may lead to false conclusions and prevent accurate identification of issue (eg, parable of blind men describing elephant); establishing groundwork (ie, trust, common ground, communication) improves ability to approach problem from variety of perspectives and arrive at better solutions |
| Commitment: pledge to become a TRUSTED colleague—to become a TRUSTED colleague, every conversation, every time, with everybody, to the very best of my ability; to be open to feedback (positive and corrective) from any of my peers and colleagues, beginning today |
| Closing remarks: quotation—Vince Lombardi (celebrated football coach) said, “winning isn’t everything; the will to win is the only thing”; similarly, speaker suggests “trust isn’t everything; the will to be trusted is the only thing”; final take-home point—problems in health care best solved by accentuating positive qualities, attitudes, and behaviors and eliminating negative ones (focusing on selves first) |
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Attributes of a TRUSTED Colleague |
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Team player |
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Responsive and respectful |
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Understands |
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Safe |
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Talented |
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Executes task |
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Dedicated and devoted |
Suggested Reading
Churchill LR, Schenck D: Healing skills for medical practice. Ann Intern Med 149:720, 2008; Dunn EJ et al: Medical team training: applying crew resource management in the Veterans Health Administration. Jt Comm J Qual Patient Saf 33:317, 2007; Frankl VE: Man’s Search for Meaning. Boston, MA: Beacon Press, 1959; Gladwell, M: The Tipping Point: How Little Things can Make a Big Difference. Boston, MA: Back Bay Books, 2002; Hurley RF: The decision to trust. Harv Bus Rev 84:55, 2006; Krug SE: The art of communication: strategies to improve efficiency, quality of care and patient safety in the emergency department. Pediatr Radiol 38(Suppl4):S655, 2008; Lee RC et al: A system analysis of a suboptimal surgical experience. Patient Saf Surg 3:1, 2009; O’Byrne WT 3rd et al: The science and economics of improving clinical communication. Anesthesiol Clin 26:729, 2008; Ostergaard HT et al: Implementation of team training in medical education in Denmark. Postgrad Med J 84:507, 2008; Salas E et al: Communicating, coordinating, and cooperating when lives depend on it: tips for teamwork. Jt Comm J Qual Patient Saf 34:333, 2008; van Pelt F: Peer support: healthcare professionals supporting each other after adverse medial events. Qual Saf Health Care 17:249, 2008; Voss JD et al: Changing conversations: teaching safety and quality in residency training. Acad Med 83:1080, 2008; White D et al: Communities of practice: creating opportunities to enhance quality of care and safe practices. Healthc Q 11(3Spec No):80, 2008; Wu AW et al: Effectiveness and efficiency of root cause analysis in medicine. JAMA 299:685, 2008.
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