Tyranny of metrics

I came across a cartoon the other day (see here) that reminded me of a visit I once made to another health care organization.  One of the hospital executives was showing our team around their C-suite, and we came to an area where they proudly displayed all of their Key Performance Indicators (KPIs).  The individual was particularly proud of the fact that the wall (and it was a large wall) was covered from top to bottom with charts showing several (and I do mean several) KPIs graphed over time.  Each KPI was displayed in color on a run chart using an 8.5 x 11 inch piece of paper.  I couldn't help but ask two questions, "Who collects all of this data and how much time do they spend each week on updating all of these charts?"  

We've unfortunately come to a point where a book by the author, Jerry Z. Muller called, appropriately enough, The Tyranny of Metrics should be required reading!  Please don't misunderstand me here, I am a big believer in having data available to quantify - objectively - either your own performance or the performance of your organization.  I loved the book by John Doerr called Measure What Matters, and I loved what W. Edwards Deming had to say on this subject when he said, "In God we trust, all others must bring data."  Finally, I have always subscribed to Peter Drucker's theory that "If you can't measure it, you can't improve it."  However (and it's a BIG however), there is no question that some leaders and organizations have gone way too far when it comes to KPIs and metrics.

But please don't listen to me.  Take what the Institute for Healthcare Improvement's President Emeritus and Senior Fellow and former CMS Administrator (and pediatrician!), Don Berwick says about metrics.  Berwick is a HUGE proponent of using data to drive improvement, but he lists "Metrics Glut" as one of his "Seven roadblocks to improving patient safety".  Say what?  Too much measurement can actually prevent us from improving?  He says, "We need to stop excessive measurement.  I vote for a 50 percent reduction in all metrics currently being used."  Mark Graban, an expert in health care improvement and author of a great blog called Lean Blog, writes of Berwick's point here, "I agree that most organizations' executives have too many metrics - not just around patient safety and not just in healthcare.  Remember, KPI stands for KEY Performance Indicators."

Berwick often refers to an example from the British National Health Service (NHS) when he talks about the problem of excessive measurement - the "tyranny of metrics."  Apparently, in the early 2000's, the NHS, trying to address the widespread problem of emergency department (ED) overcrowding, set a goal that all patients presenting to the ED should be seen, treated, and discharged (or admitted) within 4 hours of arrival.  Take a look at the following graph from a review of the NHS goal published by Julie Eatock, Matthew Cooke, and Terry P. Young:

What does this graph tell you?  Do you think it is a coincidence that the percentage of patients who are admitted to the hospital suddenly spikes right before the four-hour mark?  Almost everyone of us procrastinate and then scramble to complete our assigned task so we make a deadline.  I can imagine that these hospitals are doing the same thing, delaying admission for as long as possible and then scrambling to admit patients right before the deadline.  Here is a great example of one of the major drawbacks identified by both Jerry Muller in his book and Don Berwick in a number of speeches and presentations - gaming the system (there's even a Wikipedia page for that - see here)!  I have written a number of posts in the past on something known as Goodhart's Law (see also here and here), the concept that once performance is tied to a particular metric, the metric ceases to become useful.  The NHS four-hour goal is an excellent example of Goodhart's Law!

So, how do we avoid the "tyranny of metrics"?  While his focus was on more than just excessive measurement, Don Berwick listed the following "9 steps to end this era of greed and excessive measurement":

1. Stop excessive measurement

2. Abandon complex incentives

3. Decrease focus on finance

4. Avoid professional prerogative at the expense of the whole

5. Recommit to improvement science

6. Embrace transparency

7. Protect civility

8. Listen. Really listen

9. Reject greed

I think that some of these points are particularly relevant to the "tyranny of metrics," particularly #1, #2, #3, #5, and #6.  I talked about the IHI's concept of Whole System Measures in my last post ("How good are we really?").  What's important to realize here is that (1) there is no single measure that can adequately measure the overall performance of a health care organization (which is likely true for any organization, really) and (2) a short list of measures is preferable to a large one.  

Please do yourself a favor and read both The Tyranny of Metrics and Measure What Matters.  Tell me what you think!  Seth Godin, another blog writer, says, "Measuring is fabulous.  Unless you're busy measuring what's easy to measure as opposed to what's important."  I think everyone I mentioned today in this post would agree.  I certainly do.

How good are we really?

Benjamin Franklin once said, "Without continual growth and progress, such words as improvement, achievement, and success have no meaning."  All of us, each and every day, should be striving to get better.  As the American author Mark Twain said, "Continuous improvement is better than delayed perfection."  

Most health care organizations (at least the good ones) have adopted the mindset of continuous improvement, always aiming to get better by doing better.  The natural question follows though, what exactly are these organizations trying to get better at?  How should we quantify "better" for health care organizations?  Better outcomes?  Better financial margins?  Better patient experience scores?  Some of the above?  All of the above?

There are a surprising number of research studies in the health management literature that have attempted to address these questions.  Apparently, health policy experts don't agree on which metric(s) to use in order to assess performance.   So, I go back to my original question, what exactly are we trying to achieve when we talk about continuous improvement towards better performance?  Maybe a better question is what should we be measuring to assess our performance?

As it turns out, most health care executives don't really understand how exactly their organizations are performing.  A group of researchers at the RAND Corporation recently published a study in the latest issue (September/October 20201) of the Journal of Healthcare Management.  The study investigators interviewed 138 C-suite executives of 24 different health systems in California, Minnesota, Washington, and Wisconsin between 2017 and 2019 (these specific states were selected because they all had required public reporting of health system performance data).  They selected health systems specifically with a focus on diversity in size (small, medium, and large) and performance (low, medium, and high).  

In general, the subjective assessments of these C-suite executives did not match up with the objective assessments of their health systems (determined using the a variety of metrics - a "whole system measures" set if you will).  The subjective assessments matched up with the objective measurement of performance in only 10/24 (42%) of the health systems.  In twelve of the fourteen cases where they didn't match, the subjective assessments were more positive than the objective measurement, i.e. the C-suite executives felt that their system was performing better than they actually were doing!

The other interesting finding from this study was that in most of the cases where the subjective and objective assessments were different, the executives focused primarily on local market competition, financial performance, and patient experience data to assess their system's performance.  In contrast, where the subjective assessments matched closely with the objective measurements, executives cited quality outcome metrics as the basis for their assessment.  In other words, if you really want to determine how well your hospital is performing, make sure that you include quality of care measures in your assessment!

I have always liked the concept of using a parsimonious set of metrics to assess performance, which include (importantly, as it turns out) clinical outcomes.  The Institute for Healthcare Improvement (IHI) recommends using a system of measures that they refer to as "whole system measures" that health care leaders can use to assess their system's performance.  Importantly, these metrics are not disease- or condition-specific, but rather include metrics that assess the overall quality of care, safety, cost, and experience.

Clinical leaders need to understand how their organizations are performing from a financial standpoint, just as non-clinical leaders need to understand how their organizations are performing from a quality of care and safety perspective!  Whatever you wish to call them - "whole system measures" or even the commonly used "balanced scorecard", it's important for all health care leaders to know and understand how their organization is performing with respect to quality, safety, finance, and experience.  And when that is the case, they can truly drive to better with continuous improvement.

"Be kind whenever possible..."

I want to start the week on a high note.  The Dalai Lama admonishes all of us to "Be kind whenever possible."  He follows with something even more profound, "It is always possible."  We are living through some tough times, and I've noticed more and more that the stress of the COVID-19 pandemic has given us all a short fuse.  It's hard to remember to be patient with others, but it shouldn't be hard for all of us to treat each other with respect and kindness. 

A recent workforce study by Qualtrics found that 66% of workers report higher levels of stress since the start of the COVID-19 pandemic.  More than half of these workers report being more emotionally exhausted and more irritable at work, while nearly one-third report increased anger.  Unfortunately, increased stress can create a vicious cycle - in other words, feeling more stressed leads to even more stress!  A study published in the journal Occupational Health Science showed a significant association between stress at work and insomnia, which creates additional stress, and so on, and so on.

As it turns out, simply being on the receiving end of a rude or angry e-mail at work can impact our life at home.  A recent study by researchers at the University of Illinois suggested that if I receive an angry or rude e-mail at work, it will negatively affect my wife's opinion of her work!

All of these studies are very enlightening and very important.  And they should be enough to convince us to treat our fellow colleagues with kindness.  Given the negative impact of workplace incivility on productivity and performance, leaders need to pay attention to how the individuals on their teams are treating each other.  Now, more than ever, we all just need to take an extra deep breath and be patient and kind.  

Things are going to get better.  We will get through this.  But it's going to take some more time.  So be patient and be kind.

The trust equation

The issue of "trust" has come up several times in several meetings this past week.  I have met with a number of new leaders in transition who have talked about the need to "build trust" with their teams.  Again and again, I have offered advice by saying that building trust (or in some cases, restoring trust when a new leader takes over from an untrusted leader) is one of the most important aspects for a new leader - really, the same is true for old leaders as well.

In searching for information on "trust" these past couple of weeks, I came across a website that talked about a concept called the "Trust Equation".  The "Trust Equation" was conceived by Charles Green, who developed the concept in a book he co-wrote called The Trusted Advisor.  Trust (T) is a combination of four variables, credibility (C), reliability (R), intimacy (I), and self-orientation (S):

T = (C + R + I) / S

As you can see in the equation above, credibility, reliability, and intimacy all increase a person's trustworthiness, while self-interest reduces it (significantly so, based on the fact that is reduces the combined impact of the other three variables).  The four variables are fairly straightforward.

In my previous post (Trust), I mentioned a study by Jack Zenger and Joseph Folkman of over 87,000 different leaders which found that the three most important elements of trust were (1) positive relationships, (2) good judgement/expertise, and (3) consistency.  "Good judgement/expertise" is represented by the variable, Credibility (C), in the Trust Equation.  There is an ongoing debate about whether leaders should have both subject matter expertise and leadership/management expertise in their field (for a great discussion of this issue and more, see the excellent book, Range by David Epstein).  I believe (rather strongly) that leaders should have more than a basic understanding of the technical aspects of the work that their team performs.  Both the Zenger/Folkman study and the Trust Equation agree that credibility (a proxy for subject matter or technical expertise) is critically necessary for leaders to establish trust.

The Zenger/Folkman study's concept of "Consistency" is represented by the variable, Reliability (R) in the Trust Equation.  Here, leaders serve as role models, honor commitments, and keep their promises.  One of my mentors used to say, "I will never ask you to do something that I am not willing to do myself."  Most importantly, he "walked the talk" and followed through on that statement.  I specifically recall a time when we were short-staffed in our Pediatric Intensive Care Unit.  He not only carried his share of the clinical load, but he also ended up taking several additional weeks of service to protect the other members of our Division.  

The variable Intimacy (I) in the Trust Equation is similar to the key element of "Positive Relationships" in the Zenger/Folkman study.  Trusted leaders are the ones who are open and vulnerable to their own weaknesses or gaps - by doing so, they establish a psychologically safe environment where their teams can share their concerns.  When leaders outwardly show their own vulnerability, others on their teams will do so as well.  Leaders who generally care for their teams and get to know them on both a personal and professional level will also build trust.  Importantly, of the three key elements of trust identified in the Zenger/Folkman study, "Positive Relationships" was the most important.  For example, trust decreased by 17 percentage points when leaders were inconsistent.  However, when the "Positive Relationships" score was low, even if "Good judgement/Expertise" and "Consistency" scored high, trust fell by 33 percentage points!

The last variable in the Trust Equation, Self-orientation (S), has a negative impact on Trust.  Leaders who look out for their own self-interests are not very trustworthy.  In contrast, leaders who placed the needs of their own teams first and foremost above their own (see also, "Leaders Eat Last") are highly trusted.  Peter Drucker, the famous management guru, said, "The leaders who work most effectively, it seems to me, never say 'I.' And that's not because they have trained themselves not to say 'I.' They don't think 'I.' They think 'we'; they think 'team.' They understand their job to be to make the team function. They accept responsibility and don't sidestep it, but 'we' gets the credit.... This is what creates trust, what enables you to get the task done."

I will leave this discussion about trust with two final quotes, both from leaders whom I have learned a lot from during my career.  Both of these leaders had a lot to say about trust.  General Colin Powell, former Chair of the Joint Chiefs of Staff and Secretary of State said, "The essence of leadership is building bonds of trust in your organization."  Jack Welch, former CEO of General Electric said, "Leadership, very simply, is about two things: 1. Truth and trust,  2. Ceaselessly seeking the former, relentlessly building the latter."

Trust

I am awfully proud of myself.  I was just on a trip a few days ago and walked through not one, but THREE airport bookstores without purchasing a single book!  I haven't purchased a book on Amazon for over a month! That is highly unusual for me (see an old post, Today's word is..."Tsundoku").  Okay, I confess that I checked out a couple of books from our local library fairly recently, but I have also read a couple of the books (there are several) on my nightstand that I have left unread for quite a while.  The most recent was the book Trust: America's Best Chance  by the current Secretary of Transportation, Navy veteran, former U.S. Presidential candidate, and two-time Mayor of the city of South Bend, Indiana, Pete Buttigieg.  Overall, it was a fairly quick and easy read, but it wasn't different than what I had expected.  Rather than telling the story of his personal journey from small town mayor (South Bend is the fifth largest city in the 17th largest state in America) to presidential candidate, Buttigieg focused on what he believes is ailing the United States, namely a break-down of trust.  

Buttigieg opens the second chapter of his book with a story about tobacco advertising.  It is a well-known story that the tobacco industry downplayed the link between cigarette smoking and cancer (this was actually the subject of a movie called The Insider starring the actor Russell Crowe, who was nominated for an Academy Award for his portrayal of a Brown & Williamson advertising executive who blew the whistle on the tobacco industry).  Buttigieg mentions a 1969 report by the tobacco company, Brown & Williamson, titled "Smoking and Health" which suggested that "Doubt is our product, since it is the best means of competing with the 'body of fact' [linking smoking with disease] that exists in the mind of the general public. It is also the means of establishing a controversy...if we are successful in establishing a controversy at the public level, there is an opportunity to put across the real facts about smoking and health."  In other words, counter all of the clinical evidence linking cigarette smoking with cancer, lung disease, heart disease, etc by sowing distrust!  Tobacco companies didn't just lie about the overwhelming body of evidence suggesting that cigarette smoking was harmful, they actually tried to convince the public that smoking was actually beneficial to one's health!

How about this strategy?  The tobacco company Phillip Morris published a study ("Public Finance Balance of Smoking in the Czech Republic") performed in the Czech Republic that suggested that smoking, even if it was harmful to the public, actually helped the national economy!  The study found that found that the combination of smokers' early mortality (from the increased risk of cancer, lung disease, heart disease, etc), as well as the revenue from the tax on tobacco products outweighed the costs of health-care and lost tax revenue from early death (when people die, they no longer pay income tax).  The study found that the effect of smoking on the public finance balance in the Czech Republic in 1999 was positive, estimated at +5,815 mil. CZK!  Here, rather than trying to sow doubt and mistrust in the clinical evidence, the tobacco companies accepted the dangers due to smoking.  However, smoking was still helpful to the economy!

The Philip Morris report was unusual in that historically, tobacco companies had disputed the link between smoking and early mortality.  Here, the report used the early mortality as a selling point!  Of course, when the report was leaked to the public, Philip Morris was widely condemned by just about everyone.  As a result, the tobacco company disavowed the report and apologized for the study's conclusions.

We live in a time and place where you simply cannot believe everything you hear.  There is a concept known as Brandolini's Law, also known as the "bullshit asymmetry principle" that states, "The amount of energy needed to refute bullshit is an order of magnitude larger than to produce it."  A lot of what is out there is blatantly false, and fact checkers can't keep up with it because it is harder to refute falsehoods than it is to produce them.  And unfortunately, others are using misinformation and the lack of trust that is so prevalent today for their own nefarious ends.  Pertinent to current events, a study published in the American Journal of Public Health in 2018 suggested that fake social media accounts masquerading as legitimate users create falsehoods about vaccination, which leads to further mistrust, vaccine hesitancy, and danger to the public health.

There is a crisis of trust in America today.  Clearly, we have work to do.  Good leadership (as opposed to bad leadership) will help rebuild and regain trust that has been lost over the last several years.  We need trustworthy leaders!  Stephen Covey said, "Without trust, we don't truly collaborate; we merely coordinate or, at best, cooperate.  It is trust that transforms a group of people into a team."  He goes on further to say, "Trust is the glue of life. It’s the most essential ingredient in effective communication. It’s the foundational principle that holds all relationships."  Warren Benis would agree, stating, "Trust is the lubrication that makes it possible for organizations to work."  Secretary Buttigieg would build on this and suggest that (and I'm paraphrasing here), trust is the lubrication that makes it possible for governments and nations to work.

So how do leaders build and establish trust?  Leaders can start by making a conscious effort to "walk the talk."  Leaders should model the behaviors and attitudes that they want their teams to develop.  Leaders can also build trust with their teams by keeping their promises and being both transparent and consistent.  Angela Civitella, writing in Forbes magazine lists five ways that leaders can build trust:

1. Be a good role model

2. Tell the truth

3. Be part of the team

4. Be transparent

5. Don't micromanage

Jack Zenger and Joseph Folkman analyzed the 360° leadership assessments from over 87,000 different leaders and identified three key elements of trust:

1. Positive relationships

Leaders need to create positive relationships with other people and groups.  Leaders who are transparent and honest are more likely to establish trust and rapport.  Similarly, leaders who genuinely care about their teams are the ones that the teams will trust the most.

2. Good judgement/expertise

Leaders that are well-informed, knowledgeable, and experienced enough to understand the technical aspects of the job are more likely to be trusted.  If a leader is not a technical expert, showing that they are willing to listen and learn from their teams (and who defer to the experts) is critically important.

3. Consistency

Leaders who walk their talk and do what they say that they will do are more likely to be trusted.

Secretary Buttigieg concludes his book on a good note, "Trust is easily broken, but it can also be built - and, where necessary, rebuilt.  And the tools for such rebuilding lie, more often than not, in the hands of the people."  

"Believe"

In case you haven't figured it out yet, I love the Apple + television series, Ted Lasso.  Someone once said that "timing is everything" - that's certainly true for television and it's also true for life.  Ted Lasso came out just at the right time.  It's a lighthearted (usually - this season not always), "feel good" television show that came out in the middle of a once-in-a-lifetime pandemic when everyone needed a reason to feel good again.  Would the show have been as successful if it had been released at a different time in history?  Maybe not, but who cares.

The show is packed with motivational quotes about leadership.  If you watch the show, you will definitely notice the "Believe" sign hanging in the fictional football team AFC Richmond's locker room (see picture below).  

If you pay really close attention, you will notice a poster of legendary UCLA basketball coach John Wooden's "Pyramid of Success".  Coach Wooden based his Pyramid partially on a "Seven Point Creed" which was given to him by his father after he graduated from grammar school (and which he continued to live by throughout his life):

1. Be true to yourself.

2. Make each day your masterpiece.

3. Help others.

4. Drink deeply from good books, especially the Bible.

5. Make friendship a fine art.

6. Build a shelter against a rainy day.

7. Pray for guidance and give thanks for your blessings every day.

I think Coach Lasso would agree with both the "Seven Point Creed" and the "Pyramid of Success".  I would bet that Coach Wooden is one of Ted Lasso's heroes!  Why would Ted Lasso try to emulate Coach Wooden?  That's an easy question.  Just take a look at his long and distinguished resume.

Coach Wooden was a three-time consensus All-American basketball player for a Purdue University team that was recognized (before the NCAA Tournament) as the college basketball national champion in 1932.  His nickname says it all - he was known as the "Indiana Rubber Man" for the way he always dove for the ball on the court.  He played professionally (for the Indianapolis Kautskys, Whiting Ciesar All-Americans, and Hammond Ciesar All-Americans) while also teaching and coaching basketball in high school.  His high school coaching record over 11 seasons was 218-42.

Wooden joined the Navy shortly after the U.S. entered World War II.  After leaving the military, he coached at Indiana State Teachers College (later Indiana State University) for 2 years.  His 1947 team was invited to play in the National Association of Intercollegiate Athletics (NAIA) National Tournament, but Wooden refused the invitation because of the organization's policy of banning Black players.  He was actually invited to be the Assistant Coach at his alma mater, Purdue University for one year until then Head Coach Mel Taube's contract expired but refused, citing loyalty to Coach Taube.  His 1948 team was again invited to the NAIA National Tournament, which had reversed the policy of banning Black players.  His team lost in the finals to the University of Louisville, the only time that a Wooden team lost a championship game.

Shortly after the 1948 season, Coach Wooden was hired as the Head Coach at UCLA, where he would coach until 1975.  There was another interesting twist of fate here - both Wooden and his wife wanted to remain in the Midwest.  The University of Minnesota expressed interest in hiring him as their next head basketball coach, but inclement weather prevented them from contacting Wooden by telephone with their offer.  Believing that they had lost interest, Wooden accepted the UCLA job instead!

Coach Wooden was immediately successful at UCLA, taking a team that had finished 12-13 the previous season to a 22-7 record in his first year as head coach.  His success continued, but he was apparently not happy living on the West Coast.  When Mel Taube retired at Purdue University, he was offered the head coaching job again at his alma mater.  He refused a second time, because he had not finished out his three year contract (imagine that today - coaches break contracts all the time).

Coach Wooden would go on to lead UCLA to unparalleled success.  His team would go on to win the NCAA National Tournament an unprecedented 10 times, which included a streak of national championships for 7 years in a row!  The "Wizard of Westwood" would coach his team to 620 wins over 27 seasons, including a record winning streak of 88 games that still stands today (it will probably never again be touched).  He was inducted into the Basketball Hall of Fame as both a player (1960) and coach (1973), and he received the Presidential Medal of Freedom in 2003.

If you look closely in the picture below, you will see his "Pyramid of Success" mentioned above:

The Pyramid is as simple as it is profound.  It consists Coach Wooden's philosophical building blocks for succeeding at basketball and at life.  He wanted his players to be just as successful off the court as they were on it.  The Pyramid was developed over the course of his career, beginning when he was a high school coach and nearing completion when he ended his coaching tenure at the Indiana State Teacher's College.  There are 14 building blocks of human determination that lead to the apex block (the fifteenth), which is "Competitive Greatness."  The 10 words on each side of the pyramid - literally holding the pyramid together, if you will, lead to the top, where Faith ("Believe") and Patience overlook Competitive Greatness.  

Following his death at the age of 99 years in June 2010, all UCLA sports teams wore either a patch or helmet sticker with the initials "JRW" inside a black pyramid for the remainder of the season, in honor of his philosophy of coaching and life.  He said, "Success is peace of mind which is a direct result in self-satisfaction in knowing you did your best to become the best that you are capable of becoming."

In the spirit of Ted Lasso, I will leave you with one more quote - this time, an exchange between the owner of the AFC Richmond football team and her head coach, Ted Lasso:

Rebecca: Do you believe in ghosts, Ted?

Ted: I do. But more importantly I think they need to believe in themselves.

Believe in yourself (apparently, even if you are a ghost).  Believe - I think Coach Wooden would agree too.

Simplify your offense!

Yesterday was the start of the pro football season (American football, not the Ted Lasso kind of football popular everywhere else around the world - incidentally, the fictional character, Ted Lasso, did get his start coaching college football for the Wichita State Shockers).  I heard that there were 15 NFL teams with new starting quarterbacks yesterday, including a couple of rookies.  It seems that every year, we hear that coaches try to "ease in" these rookie quarterbacks by simplifying the offense.  It's not universally true that pro football teams always run offensive schemes that are particularly more complex than some of the best college football teams (although this is commonly the case).  Rather, the players are just so much more competitive and talented compared to most of the players that rookie quarterbacks play against in college.

The American author and pediatrician (well, that's pretty awesome!), John Gall would be quite pleased with the coaches who "simplify the offense" for their rookie quarterbacks.  Gall wrote a book in 1975 called,  General Systemantics: An essay on how systems work, and especially how they fail.  One of the statements in his book is now known as Gall's Law.  Gall's Law can be summarized as follows:

"A complex system that works is invariably found to have evolved from a simple system that worked. A complex system designed from scratch never works and cannot be patched up to make it work. You have to start over with a working simple system."

In other words, "simplify your offense!"  Think for a moment and then ask yourself this question - if you were going to change a process in your hospital, how would you start?  Would you take the new process and implement it in every single inpatient unit of the hospital, or would you start smaller and try it in one inpatient unit first?  We call this "a small test of change" - the concept is to start simple and small, test to see whether the process works as you predicted it would, and if so, spread the change more broadly.  If you follow this strategy, you are essentially running a PDSA Cycle - Plan, Do, Study, Act!

Start small.  Simplify the offense.  Gall's Law.  It all makes really good sense.

The four archetypes of disruptive physicians

Hospitals are finally starting to take the problem of disruptive physician behavior seriously.  Several years ago, the Joint Commission released Sentinel Event Alert 40 ("Behaviors that undermine a culture of safety"), which established a link between disruptive behaviors and medical errors, poor patient/family experience, worse outcomes, increased staff turnover, and higher costs of care!  Most physicians agree that disruptive behaviors negatively impacts patient care (one survey found that 90% of the physicians agreed with the statement that disruptive behavior leads to worse care).  And while most studies suggest that only about 3-5% of physicians are responsible for these disruptive behaviors, even just a few disruptive physicians can have a profound impact on the overall culture of an organization.

The cost of disruptive physicians is not trivial.  The combined costs of disruptive physician behavior (due to the impact on staff turnover, patient outcomes, and cost of care) for a 400 bed hospital exceed $1 million per year.  Given the negative impact of disruptive behavior on the quality of care (poor outcomes and poor patient/family experiences) and costs, both medical staff leaders and physician executives must address these behaviors when they occur and create the kind of organizational culture where these kinds of behaviors are not acceptable.  

While there are a number of different definitions for disruptive physician behaviors (apparently, disruptive physician now has its own Wikipedia page), the American Medical Association defines it in their Code of Medical Ethics as "personal conduct, whether verbal or physical, that negatively affects or that potentially may affect patient care."  Examples include (but are certainly not limited to just these) angry outbursts, throwing objects, chronically showing up late to clinic or the operating room, ignoring pages and/or telephone calls, refusal to follow hospital policies, and demeaning staff.  However, as discussed further below, not every disruptive physician is the stereotypical hot-tempered individual that is prone to frequent, angry outbursts and frequently portrayed in the media (think Hugh Laurie's character, Dr. Gregory House from the television series, House or Alec Baldwin's character, Dr. Jed Hill in the 1993 movie, Malice).

One group of investigators defined four common archetypes of the disruptive physician that I have found particularly useful, particularly.  Again, some of these descriptions may not fit your typical description, but they can be disruptive nonetheless.  Here are the archetypes with a brief explanation:

1. The Know-It-All:  Most, if not all, physicians are highly intelligent.  However, there are some physicians that feel the need to prove their intelligence to the point where they intimidate those around them.  They become unapproachable and can never see alternative viewpoints or opinions.  They know best, so it's always "their way or the highway!"  

2. The Insecure: I would say that the aforementioned "Know-It-All" is more common than the "Insecure" physician, at least in my experience.  These physicians are constantly doubting or questioning their own ability and frequently seek affirmation from others around them.  Their insecurity often results in being overly thorough and "ruling everything out" before establishing a diagnosis.  When it comes to clinical decision making, these physicians are often paralyzed.  

3. The Flake: These are the physicians who are always asking for someone to cover a clinical call or shift due to conflicting plans.  Unfortunately, they are almost never able to pay someone back in return.  While generally pleasant to be around, these physicians are frustrating as colleagues.  They almost never finish their clinical documentation on time, and frequently fail to respond to telephone calls or e-mails due to "patient care responsibilities."

4. The Combatant: These are the classic, stereotypical disruptive physicians.  They have short tempers and frequently display temper tantrums.  They frequently issue ultimatums (especially to administrators - "Fix this problem or I will send my patients somewhere else") and rule by intimidation and fear.  

During my career, I have worked with disruptive physicians representing all four archetypes.  When we think of disruptive physicians, we tend to think of either the "Know-It-All" or more commonly, the "Combatant."  However, the "Insecure" and the "Flake" can be just as disruptive.  The article offers a general framework for dealing with all four archetypes, as well as specific recommendations for dealing with each individual archetype.  At least for now, I will leave that for a post in the future.  

Organizational enemas

Rear Admiral Grace Hopper, a computer scientist who is perhaps best known for helping to develop the computer programming language, COBOL (an acronym for "common business-oriented language").  She is also known for being the first person to find a computer bug (the common term for an error, flaw, or glitch in a computer program).  As the story goes, it was a warm, late summer day in 1947 (September 9, 1947 to be exact) when a team of engineers and computer scientists at Harvard University were working on the Mark II computer.  The computer program kept delivering an error.  According to legend, Hopper opened up the back of the computer to check one of the relays and found a dead moth.  She carefully fished the moth out of the computer with a pair of tweezers, taped it into her logbook, and wrote the message, "first actual bug found."  Hopper reportedly said afterwards, "From then on, when anything went wrong with a computer, we said it had bugs in it."

It's a great story, but I have another reason to admire Admiral Hopper that is more relevant to today's post.  Admiral Hopper once said, "The most damaging phrase in the language is It's always been done that way."  She actually said a lot about people's resistance to change - here are a few more quotes:

"I've always objected to doing anything over again if I had already done it once."

"Humans are allergic to change.  They love to say, 'We've always done it this way.'  I try to fight that.  That's why I have a clock on my wall that runs counter-clockwise."

"A ship in port is safe, but that is not what ships are for.  Sail out to sea and do new things."

I've posted a lot about "change" and "change management" in the past.  I am by no means an expert in this area - there are countless articles and books on managing change that are much more valuable than anything that I have written in the past.  However, I write about "change" because "change management" is one of the most difficult aspects of being a leader.  

John Kotter developed an 8-step change model that is commonly cited and used today.  The first step is to "create a sense of urgency," taking advantage of the fact that people often respond better to change when there is a crisis or so-called "burning platform."  In my experience, it doesn't really matter if there is a "burning platform" or not, there will always be some individuals who will resist change and do everything in their power to fight it.  These are the "active resisters" identified by Sanjay Saint and his colleagues in an excellent study on change management specific to hospital infection prevention and control practices ("How active resisters and organizational constipators affect health care-acquired infection prevention efforts").  

Saint and colleagues surveyed 86 hospital executives, infection prevention specialists, nurse managers, hospital epidemiologists, and frontline physicians and nurses about barriers to the implementation of evidence-based practices around hospital-acquired infections (e.g., central line infections, surgical site infections, etc).  "Active resisters" were those individuals who vigorously and openly opposed the various changes in infection prevention and control practices.  In some cases, these individuals would counter the change with the "We've always done it this way" or "That's not how I was trained."  In other cases, the resistance was more blatant and vehement.  For example, in one hospital, a senior surgeon openly instructed the other members of the surgical team to be noncompliant with one of the changes in the surgical site infection prevention bundle.

There was another important category of individual who was just as detrimental to the success of the change initiative - the so-called "organizational constipator".  These were the individuals who passively resisted any change effort, often by withholding resources (money and/or personnel) or pushing back important deadlines.  Unfortunately, these individuals are often the most challenging group to address.  While the "active resisters" are often vocal and open about their resistance to change, the "organizational constipators" are more covert.  They may say the "right" things in public, but silently oppose the change.  

Fortunately, there are ways to overcome both active resistance and organizational constipation.  One of my former PICU colleagues, Dr. Maya Dewan, suggested a couple of strategies to overcome the "active resisters" and the "organizational constipators" - in my own attempt at tongue-in-cheek humor, what I call the "organizational enema"!  Dr. Dewan suggests:

1. Follow the evidence!  Use evidence-based guidelines and/or expert consensus statements whenever possible.

2. Show the data!  Provide benchmarking data both within your own organization as well as peer organizations.

3. Recruit champions!  Depending on the change initiative, both physician and nurse champions will frequently be necessary.  Leverage their experience, expertise, and reputation to model and promote the change.

4. Bring the organizational constipators to the table!  Engage these individuals early on in the planning process, even if it means developing work-around strategies.

5. Be a relentless pursuer of improvement!  Don't give up.  You will encounter both active and passive resistance.  However, if you follow this model, data and evidence will be on your side.

"The only true wisdom is in knowing you know nothing..."

It seems like the more I learn, the less I really know.  Hence the title of today's post is one of my favorite quotes by the ancient Greek philosopher Socrates.  I don't recall where I first heard this analogy (and I may have embellished it a bit from wherever and whomever I first heard it), but I have often described the brain's capacity for new knowledge as a flat table.  Everything you learn - every new bit of knowledge, if you will - is like a marble.  When you learn something new, you add a new marble to the table.  As you get older, the table starts to fill up of course.  Eventually, in order to add a new marble to the table (i.e. a new bit of knowledge), another marble has to fall off the table!  I usually add a joke at the end that when you get too old and forgetful, you really have just lost all your marbles (incidentally, that's not where the old saying of "losing all of your marbles" comes from)!

We are learning a lot about intelligence.  As we learn more, we are starting to find out that many of the ideas and concepts about intelligence that we previously accepted as fact, no longer hold true.  For example, animals are a lot more intelligent than we give them credit.  Have you ever heard the term "bird brain"?  Birds have tiny brains relative to humans (and other primates too, for that matter), and for at least a hundred years or more, the size of the brain was thought to be a proxy measure for intelligence.  Hence, the term "bird brain" was used to refer to an annoyingly stupid person.  

As it turns out, birds have tiny brains so they can fly.  And, as it turns out, birds are a lot smarter than we think.  One of my favorite stories is about the ravens living on the grounds of the Tower of London (for another great story about my trip to the Tower of London several years ago, see my post, Risky Business).  Legend has it that the kingdom of England will fall if the six resident ravens ever leave the fortress (the legend is thought to have been started by Charles II).  Suffice it to say, these ravens are very well cared for by the "Beefeaters" (the also legendary Yeoman Warders).  Perhaps these birds are smart enough to realize that there's no reason to leave?  They literally get the royal treatment!

Ravens, as it turns out, are incredibly smart.  Humans have always been placed on a higher level of intelligence because we can think about and plan for events in the future.  Apes and other primates share this level of cognition, at least to some extent.  Surprisingly, so do ravens!  A few years ago, scientists were able to show that ravens can anticipate a future event based upon past experiences, i.e. their memory!  These scientists were also show that ravens can use tools and barter for food!  For example, when food was placed inside of a long tube, ravens were able to use a stick to poke the food out of the tube!

Have you seen the video about an octopus that can open a jar?  Or the Netflix movie, "My Octopus Teacher"?  Have you ever listened to the Beatles song, "Octopus Garden"?  Octopuses are extremely intelligent animals too - some would say that they are just as intelligent as cats and dogs!

Okay, I understand that ravens (and maybe even octopuses too) are not too distant from other mammals on the evolutionary tree.  Would you be more convinced if I claimed that insects appear to be intelligent?  I have also posted in the past about a study that showed that honey bees understood the concept of zero (see Weird Science).  I will admit, that is pretty cool.  But prepare to have your mind blown!  What about the poor, brainless slime mold?

As it turns out, even slime molds are smarter than we thought.  An article published in the journal Nature ("How brainless slime molds redefine intelligence") presented findings from a number of studies of a particular species of slime mold (Physarum polycephalum), commonly known as the "Sponge Bob Square Pants" slime mold, can "solve mazes, mimic the layout of man-made transportation networks and choose the healthiest food from a diverse menu."  Now, THAT is incredible!  

We are at a time in history when we understand - at an extraordinary level - the inner workings of the human body.  However - and it's a big however - we still have a relatively infantile understanding of the workings of the human brain.  As Socrates said, "The only true wisdom is in knowing you know nothing."  As intelligent as we are, we still know relatively little about intelligence.  Just look at what Sponge Bob Square Pants slime mold can do.  Simply amazing.